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ON 



CEKTAIN OF THE DISEASES 



OF 



YOUNG CHILDREN. 



OBSERVATIONS 



ON 



CERTAIN OF THE DISEASES 



YOUNG CHILDREN. 



BY 

CHARLES D:"MEIGS, M.D., 

Professor of Midwifery, and the Diseases of Women and Children, in the Jefferson Medical 

College at Philadelphia; Member of the American Medical Association; of the 

American Philosophical Society, and one of the Council ; Vice-President 

of the College of Physicians of Philadelphia ; Consulting Physician 

to the Pennsylvania Institution for the Instruction of the Blind ; 

etc. etc. 




PHILADELPHIA: 
LEA AND BLANCHARD. 

1850. 



4^ <o 



Entered according to the Act of Congress, in the year 1850, by 

CHARLES D. MEIGS, 

in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTEUS. 



PEEFACE. 



The courses of public lectures in the Jefferson College have 
for many years opened on the first Monday in November. 

At the last session, held in 1849-50, the lectures commenced 
at the middle of October, on a plan which will probably be for 
the future adhered to in that institution. 

In October, 1849, as a considerable number of students had 
already assembled, I engaged to address to them several pre- 
liminary Lectures on the subject of children's diseases. The 
following pages contain the substance of what I then said to the 
Class who honored me with their attendance. 

Inasmuch as the regular business of my professorship was to 
commence on the first of November, and as the chief object of 
my appointment is to give instruction at that College on Obstetrics, 
I felt obliged to break off the series of remarks on disorders of 
children, in order to lay the foundations of such doctrine on 
Midwifery as I proposed to teach. 

In the course of the winter session, there was no further oppor- 
tunity for me to take up seriatim the subject which I had opened 
in the month of October. I desire not to be misunderstood, as 
saying that I did not address any further remarks to the Class on 
the management and sickness of young children. I have con- 
sidered it as a part of my duty, in all the courses I have delivered 
at the College, to take frequent and all available occasions to 
treat both of children's disorders and those of women. 

But inasmuch as the opportunity I enjoyed in October, 1848, 
enabled me to speak more especially without reference to Ob- 



VI PREFACE. 

stetrics or Midwifery, I have supposed that I might do a service, 
not unacceptable to my students, by printing this small volume, 
which I beg leave to dedicate to them. 

I hope that such of them as may meet with it, wdll remember 
the hours of their student-life passed with me in the consideration 
of these topics ; and that, if they then took any real interest in 
the views I presented to them, they may be pleased to find those 
views more clearly expressed in these pages. 

To the medical public, I beg to say that these observations on 
certain of the disorders of young children make no pretension as 
a systematic work. Indeed, I have not indulged any intention 
to make a systematic work on the subject, seeing that the place 
is already occupied with numerous valuable books, presenting a 
complete body of doctrines on children's diseases. 

To that medical public, w^hich has claim to my heartfelt grati- 
tude for the kind reception of other works of mine, I humbly 
present these observations, hoping that some of my suggestions 
as to theory and practice in the cases, may not be destitute of 
both interest and usefulness. 

CH. D. MEIGS, 
324 Walnut street, Philad^a. 
Aug. 23d, 1850. 



TABLE OF CONTENTS. 



CHAPTER I. 

PAGE 

Diagnosis 17 



CHAPTER IT. 
Caput Succedaxeum ..,....., 49 

CHAPTER III. 
Inflamed Eyes , 51 

CHAPTER IV. 

CORYZA ,..,... 57 

CHAPTER V. 
BoTVEL Complaints 63 

CHAPTER YI. 
Jaundice 79 

CHAPTER VII. 

Dress.,, 87 

CHAPTER VIII. 

Cyanosis Neonati ,,,,„.„.,,. .o.,.,. »........, ,,o...... ...,.,, 92 



Vm TABLE OF CONTENTS. 



CHAPTER IX. 

FA6K 

Respiratory Disorders 120 



CHAPTER X. 
Whooping-Cough 152 

CHAPTER XI. 
Laryngismus , 164 

CHAPTER Xn. 
Scarlatina 191 



ON 



CEETAIN DISEASES OF CHILDREN. 



CHAPTER I 



It is incumbent on me, as a Professor in the Jefferson Medical 
College, to deliver Lectures on the diseases of children, which is 
considered an important department of the professorial chair. It 
is an important one, on account of the supposed difficulty of the 
subject; and still more so, on account of the vast number of pa- 
tients, in the class of young children, that come under the care of a 
medical man in the course of his career. Moreover, it is important, 
as involving the interests and the feelings of families, as v^tII as of 
the public in general. The disease of a young child, it seems 
to me, is by some looked upon as a matter of less moment than 
the disease of an adult; and yet the life of a young child is 
equal in value to that of a grown man. Children are the inheritors 
of the whole earth: men are mere present possessors and cus- 
todians, holding it for the use and in behalf of the children of the 
family, which may consist of six persons, a father, a mother, and 
four children. It is of the diseases of children that I am about to 
speak. 

Those who would be physicians, must have more to do with 
children, than with men or women: there are probably at this 
moment, live hundred millions of children in the world ; it is even 
probable that the number may amount to six hundred millions. 
Twenty-four millions are born every year, and far more than 
one-half the annual mortality in the world, is among children 
under six years of age ; hence, the interest, the prosperity, the 
usefulness of the physician, are intimately connected with his 
knowledge of the diseases of children. 
2 



18 DIAGNOSIS. 

But this knowledge is generally deemed a very difficult and 
unsatisfactory branch of medical acquirements; — Bouchut says so 
in his 93d page. It is unsatisfactory to the public, because the 
public will not believe that physicians can understand the diseases 
of children as clearly as they can understand those of adults. 

It is certainly a very prevalent sentiment, even among the more 
intelligent portion of the community, that to put a young child into 
the hands of the physician, is to expose it to a considerable risk ; 
they call the physician because they have no one else to refer to, — 
they often call him distrustfully and doubtingly, — often, the doctor 
is a pis aller, when a child is sick. I don't assert that this is 
universally the case; for there are many intelligent people who 
know that the physician knows what he is about, and there are 
millions of credulous persons who believe implicitly even the 
audacious lies of the most unblushing quack, and swallow his 
nonsense and his drugs with equal appetite. 

It is supposed, by the public, that the physician cannot under- 
stand the diseases of children because children cannot speak or 
explain their sensations. But, a knowledge of the diseases of 
childhood is not more difficult to obtain, than that of the maladies of 
adult persons, because, in either case, the medical man relies on 
his own observation, and not upon statements he receives. The 
opinions of a patient in regard to his own case, as to the diagnostic, 
or as to the therapy, are, for the most part, utterly indifferent in 
the mind of the physician : he does not ask a patient's opinion in 
the diagnosis of a phthisis, of a hydrothorax, of an endocarditis, 
of a pleuritis, of a typhoid fever, of an exantheme, of a neuro- 
pathy, &c. When he seeks to find out their nature and seat, he 
interrogates the organs ; he knocks at the door of the functions, and 
they admit him to see for himself; he inquires of them, and they 
have voices to answer him ; for there is a language of the organs, 
and the functions speak with tongues, and the speech is plain, 
direct, vernacular, true — for it is the voice of nature that speaks, 
and nature cannot lie. But, the speech of man is a human inven- 
tion, full of imperfections, full of double meanings, often directed 
by a false heart, or a misapprehending reason; — men say there is 
pain, when there is no pain ; or they say there is no pain, when 
there is intolerable anguish; men say they are sick here, when, 
in fact, they are sick elsewhere. They know not where they are 
sick, nor how ; it is the physician's affair to find it out. 



DIAGNOSIS. 19 

"How do you do, to-day?" said I to a lady. 

"I am very sick, indeed, doctor." 

" How are you sick — where are you sick ?" 

" I have had a terrible chill, which made my teeth chatter 
together, followed by fever, violent headache, pains in the back 
and limbs, and unappeasable thirst; I am dreadfully ill." 

" Have you pain in the abdomen?" 

"No." 

"Have you any pain in the thorax?" 

"No." 

"Pain in the great joints?" 

"No." 

"Have you not a lump in your breast?" 

" No, I have not." 

"Yes, you have." 

"Indeed, I have not." 

"No," says a witness, — "I have examined it with the greatest 
care." 

" When was it examined?" 

"Just now." 

"Will you let me examine it?" 

"Yes." 

" Well, then, does not that hurt you?" I touched the breast. 

The answer was an outcry; she had a lump in her breast; she 
had a weed in her breast, and did not know it. Suppose she had 
been dumb and deaf — would there have been any bar to my diag- 
nosis in her surdmutism? 

A friend of mine had lodgings for the summer, twenty miles 
from the city; his daughter, two years old, was seized with a fit 
of inextinguishable crying; she screamed all the time that she 
was awake. 

On the morning of the second day, as her distress continued, he 
became much alarmed, and resolved, accompanied by his lady, to 
bring his child to me. They arrived at tneir city residence, and 
sent for me by an urgent messenger. I heard the child's voice 
from the third story, while I was in the lower hall. My friend 
began to explain the nature of the case, and to set forth all his 
alarm for his dear daughter. I stopped him, saying, "I hear her 
crying now, do I not?" 

" Yes, that is her voice ; she is in the greatest distress." 



20 DIAGNOSIS. 

" She is crying with an ear-ache," said I. 

" Ear-ache! How do you know that, doctor?" 

*'Come with me to the nursery, and I will prove it to you," 
said I; " I know the voice of the ear-ache." 

When we came into the room, the child, surprised by my pre- 
sence, ceased for a moment to scream. "Now," said I, " see if I 
don't prove to you that she has an ear-ache." I approached her, 
and putting the palp of my thumb on the right meatus auditorius, I 
suddenly pressed the cartilaginous tube inwards upon the ear; — 
the child merely looked surprised at my rudeness ; she did not 
cry. "It is not the right ear," said I. I next repeated the same 
movement as to the left ear, and she screamed as if she would go 
into convulsion. " There," said I, " I have hurt her ear for you, 
by a slight touch, and she cries with the same voice that I heard 
when I was down stairs ; I knew that it w^as the ear-ache then, and 
I am sure of it now, — this touch is the diagnostical test." The 
cry was a test. 

If a child have a disease of its lung, which makes it cry, it is 
probable that the cry will be modified by the modification of the 
respiratory movement involved in the pulmonary disease; and 
therefore, the pulmonary cry will be a peculiar cry. Such a cry will 
be very different from that occasioned by a flatulent colic, or by a 
griping of the bowels ; because, the cry of distress from a troubled 
intestine does not necessarily involve any modification of the re- 
spiratory act ; therefore, the cry will be different. The same is true 
with regard to the phonic expression of cephalalgia, or head-ache. 
The child with ear-ache may cry for hours, one with a pulmonary 
pain will scarcely utter sharp and protracted cries of distress. With 
a pain in the head, there will be an occasional scream, short, 
sharp, and quick. The cry of a suffering intestine is loud and 
prolonged, with frequent intervals of rest; the mouth and throat 
are opened wide, so as to utter the loudest sounds. A child with 
a pain in a great articulation, will utter a cry occasionally only, 
which will coincide with some spontaneous or forced motion of 
the joint. 

A young child suffering w^ith strong pain in the urinary blad- 
der, or the lower part of the rectum, will express the distress with 
a peculiar cry; in like manner, it will tell if the pain is in its 
lung. 

A gentleman having an only son, some three months old, came 



DIAGNOSIS. 21 

to tell me that his child was sick. He had already had the misfor- 
tune to lose two children, and had very little faith left in doctors. 
Said he, " my child is very sick, and I wish you to come and see 
it;'' adding, ''if you think it is worth while. You know," said 
he, "that with regard to the complaints of young children, it is all 
guess work; for they can't explain anything." " Guesswork!" 
said I; "I feel more at home in asking the child what is the mat- 
ter with it, than in asking you what is the matter w^ith yourself. 
I can always know what is the matter with the child, for it never 
misleads me, but men and women constantly mislead me or 
endeavor to do so." We went to see the young child, — a beau- 
tiful bright young baby, lying upon a pillow, upon its nurse's lap. 
The patient appeared to be in consummate health, and perfectly 
happy and contented. I was told that the child was, to all appear- 
ances in good health, save in this, that when it was necessary to 
change its diaper, it invariably screamed so violently, as to alarm 
them. I examined its physiognomy, its pulse, its respiration, 
its temperature, its coloration, the state of its epigastrium, and 
hypochondrium ; its umbilical and hypogastric regions, without 
discovering any signs of indisposition in any of them ; the bowels 
were regular, and the appetite good. The napkin was taken off, 
and in the act it screamed, — a sudden, sharp, impatient cry of the 
keenest distress; but, as soon as it was left to itself, it became 
complacent again, and as happy as a bird. I now took hold of 
its left foot as it laid upon its back upon the pillow, and flexed 
its leg upon the thigh, making the heel touch the buttock, and 
I flexed the thigh upon the body. I flexed and extended by 
turns the foot, all parts of it, and compressed the limb from the 
hip to the foot, which gave the child not the least uneasiness. 
I rotated the limb inwards and outwards, strongly, without dis- 
tressing it. " The malady," said T, "is not in its left leg." I 
now took hold of the right foot, and flexing it strongly, pressed 
the thigh against the belly, and then extended the whole limb 
without giving the child any pain. I flexed the leg upon the thigh, 
making the heel touch the buttock, but it gave no pain, — but when 
I held the thigh at right angles to the body, and then attempted to 
extend the leg, I gave it the most acute pain, which ceased as 
soon as I let it alone. 

Said I to the father, " when I extend the leg upon the flexed 
thigh, the child has pain ; the pain is in the synovial capsule of 



22 DIAGNOSIS. 

the knee-joint, — it is articular disease; and as there is no visible 
swelling, nor symptom of bruise about it, I shall suppose that 
it is an arthritic disease ; I suppose that it has taken cold, and has 
a slight rheumatism of its joint. Do thus and so, and in a few 
days the child will probably be well." My orders were obeyed, 
and I had no further trouble with it. 

Here, then, nature spoke the truth, — here was a language of 
the organs. The brain speaks, the lungs, the stomach, the bow- 
els, the teeth, the joints, the marrow, the organs of the senses, — 
each has a language of its own, — so that the body may be com- 
pared to a great polyglot, since so many organs as it hath, so 
many vernaculars hath it. 

There is a rich mine of diagnoses in the physiognomical ex- 
pressions of the human face, but no man can write them; — an 
artist may paint, but no printer can print them ; he that would pos- 
sess the wealth of such treasures, must dig for them himself in the 
clinical mine. One may look through the eyes down into the soul^ 
into the most intimate life-cell, and read its expression there ; be- 
cause the cerebro-spinal axis and the ganglionic nerves often ex- 
press their patible conditions clearly and plainly through the eyes. 
The whole temper of man, moral and intellectual, as well as 
physical, is written in legible characters upon his countenance. 
There is nothing more common among men than to trust, or abhor 
their brethren, upon the faith of their physiognomical expression 
as to intelligence, as to probity, as to purposes. In like manner, 
his health and security, and his prospects as to life and death, are 
discoverable by a glance at his face, gesture, or decubitus. 

I would rather ask questions as to its health, of a baby a month 
old, than of its mother; the mother will be very apt to say, if it 
have fever, *'its head is as hot as the burning fire coals ;" but the 
child's head says it is merely rather warm. The touch of its skin 
has told me the truth, as relates to its calorific function ; if it were 
in plain English to tell me how hot it is, it might perhaps say as 
its mother did, " as hot as fire," but, my perception of the rate of 
its calorific function, since it cannot speak, will not be modified 
by any respect for the speaker, — I shall perceive its true rate, 
without exaggeration or diminution of its intensity. 

The mother will say that the child is dreadfully oppressed in 
breathing; but, when I count the number of its respirations per 
minute, and when I see that they are full and ample, or imperfect 



UNBORN CHILDREN. 23 

and incomplete, — when I compare the rate of its respiration with 
the effect of its respiratory function in developing its animal tem- 
perature, its color, its innervative force, I appeal to a source of 
information which cannot deceive me, for it is not a human intelli- 
gence which tells me of the fact, — a human intelligence swayed 
by motives, biassed by emotions — but I hear the voice of nature 
speaking to me, and showing me in the rate of the functions, 
the state of the functioning organs. And so, with regard to the 
functions of all the noble parts of the body, — one may read them 
in the book of nature that lies open before him, without referring 
to the ignorant impressions of a bystander whose relation of the 
case, is, like a lawyer's brief, too apt to make the wrong the better 
reason. 

But we are speaking of the diseases of children, and we may 
ask the question — who are children ? All children ; children in 
the womb are children: and their mothers speak of them as if 
they knew them to be children — "the child moves" — "the child 
is restless" — "thecMc^is asleep" — "there must be ^t«o" — "I 
do believe I shall have twins^ Now in using these words, she 
admits that the unborn of the womb are children, and, indeed, 
they are often sick children; they are children wounded; they 
are children dying, and needing the aid of a physician, and de- 
pending on his skill and judgment for their rescue. They require 
his care, and it is his duty to be the conservator of their health, 
conducting them through the narrow portals of existence, and 
placing them securely upon the great stage of the world. 

The life of the child in utero is always different from that of the 
respiring child, the breathing child ; its wants are few, and its 
sources of supply for those wants are scanty and limited ; they are 
contained within the area of the placenta. It can scarcely re- 
quire more than that which is necessary for the development of 
its organic existence; it has no motive nor ability to exercise 
its prehensile power, its locomotive faculty, its vision, its audi- 
tion, its olfaction, or its gustation; and if its tactile sense be 
really the most active of its senses, it is yet true to say that even 
its tactile sense must be dull and obscure, since the paucity of its 
material for oxygenation, renders it impossible for the unborn 
child to possess an active and vigorous intellectual perception. 
The quantity of oxygen which the child may be supposed to be 
capable of taking from the placental superficies of the uterus, by 



24 UNBORN CHILDREN. 

whatever means that transfer may be made, is but a small quan- 
tity; but, be it great or small, the healthful condition of the noble 
parts, and of the ignoble parts of the child's constitution, must be 
greatly modified by whatever may serve to increase or diminish 
the quantity of vital air imparted to its blood. 

Children in utero, are the frequent subjects of diseases that 
destroy them before they are born, and which it is interesting to 
know, because cases occur in which a discovery of the cause of 
death of the still-born, may be of great consequence to the peace 
of families, or of individuals. It is perhaps of little moment for 
us to know that a child in utero may be the subject of a tertian 
fever. Indeed, it is scarcely certain that w^e can know it, since it 
is only after its birth that we can become acquainted with its real 
condition. True it is, that by means of the stethoscope, we may 
auscult the heart of the unborn child ; we may find that the fre- 
quency and impulse of the cardiac action is greatly augmented, 
and even that it begins to be so at a time fixed, and that the re- 
currence of the phenomena is subject to a law of periodicity. 
Dr. Graetzer takes it for granted that children may suffer from 
intermittent fever, and seems to rely upon the report of a case 
that fell under the clinical observation of Fernelius : it was that 
of a woman laboring under a quartan fever, who gave birth to a 
child, which not long afterwards was seized with a quartan. But 
such an occurrence does not prove that the infant was affected 
with the disorder while in its mother's womb. 

As little faith ought to be placed in another example that he 
cites from Paulini, in the Ephem. JYat. Curios., of a Mad. Meissen- 
thurm, the wife of a soldier, who had a quartan in the second 
month of pregnancy, and who, in the latter periods of utero-ges- 
tation, clearly perceived, as her paroxysms came on, that the child 
became restless, trembled, and moved itself from side to side. 
After its birth, it was seized with quartan paroxysms at the same 
hour that its mother's attacks returned, and continued to do so 
for a long time. 

Such information is barely inferential, it cannot be positive, 
and is only useful after the fact, if at all. 

That a child in utero may be the subject of small-pox is unde- 
niable, but to know it before the birth, is of little advantage, since 
the knowledge is inapplicable to the fulfilment of any therapeu- 



UNBORN CHILDREN. 25 

tical or chirurgical indication. The case must ever be uncertain 
until the birth. 

I have seen a child born while the mother had a forming erup- 
tion of violent small-pox. It seemed to be in good health, not- 
withstanding the intense variolous fever of the parent. I vacci- 
nated it immediately, and it took the breast, which had many 
pustules upon it. The vaccine disease passed regularly and favor- 
ably through all the usual phases, and no inconvenience was 
experienced by the young infant from having been imprisoned in 
the womb of a mother who had for several days been the subject 
of so terrible a malady. This case shows that we cannot know, 
ante partum, whether the child is attacked or no. Some children 
have had the eruption while in the w^omb. 

As to any therapeutical advantages to be derived from a study 
of the intra-uterine diseases of children, I am unable to speak. 
It is enough for us to know that they are sick, and dying or dead. 

There are women who lose the child in the womb, in con- 
sequence of imperfect development of parts belonging strictly to 
the child, or from the imperfect development of parts that are 
accessary to the child's nature and wants. 

The child is contained in the womb, whose parietes are protected 
against its contact by the double membranes of the ovum, to wit, 
the chorion and the amnion, as well as by the caducous coat of 
the uterus, so that when it moves in the womb it touches 
it not; it touches only its own amnion, the impulse being con- 
ducted through the chorion and caduca to the sentient paries of 
the womb itself; the child, in fact, touches no part of its mother 
except by its blood : — the remark has often been made that the 
blood is the flowing flesh. Oken says, that the blood is the fluid 
body, and the body is the fixed and rigid blood. Well, the 
child places its fluid body, if Oken's idea be correct, in contact 
wdth the fixed or rigid blood of its mother, in order to take from 
her the materials for the augmentation and perfection of its blood, 
whereby it may, more surely, carry on its own proper develop- 
ment. 

It is principally to circumstances connected with the state of 
the child's blood that the attention of the physician is, and must 
be turned, since he can by no means have access to the body of 
the child, whereby to discover methods of influencing that body 
as such, but he can modify the blood of the child by modifying the 



26 DIAGNOSIS. 

health of the parent ; and he is capable, in many instances, of 
ascertaining that the child's blood is undergoing strange modi- 
fications from the modality of its mother, and from modifications 
of her functional forces. He knows, that if the mother live in an 
impure atmosphere, or have a diseased lung; or if the mother have 
a disease of the nature of a cyanosis, the child whose blood touches 
hers, cannot probably derive from her vitiated blood a due amount 
of the vital air of it, and as a wise physician, he will modify her 
condition by sending her into a better air, by curing her lung, by 
correcting her cyanotic malady with a view of saving the un- 
born child in the womb. Again, — in the treatment of labors, the 
physician will consider himself a person appointed to take care of 
the health and security, not of the mother alone, but that of the 
child also, and he will carefully supervise the condition of its 
health in the only way in which he can possibly have any cogni- 
tion of its state — to wit : by auscultation of its heart through the 
muscular and other integuments beneath which it is concealed. 
He knows that the child's heart, at or near the term of utero- 
gestation, beats more or less unsteadily, and that the number of 
pulsations will be found to range between one hundred and thirty 
and one hundred and fifty beats per minute. By means of his 
auscultation he is fully enabled to determine the question as to 
the symmetrical innervation of the heart, because he will be en- 
abled to ascertain whether the first and second sounds follow each 
other with a perfect rhythm, or whether they are asymmetrical, 
as in palpitation of the organ. If the physician knows that the 
placenta of a child is, and has been, during a certain space of 
time in a labor, subjected to the unmitigated pressure of her 
uterus, compressing it without the intervention of any of the 
waters, against the superficies of the child's body, his auscultation 
will teach him whether the pressure is dangerous in degree or in 
duration, and he will take his measures, accordingly, to rescue the 
child from such danger. He will, perhaps, have read the follow- 
ing case, interestingly related by that intelligent physician. Dr. 
Evory Kennedy, in his work on obstetrical auscultation. 

"A woman came into the lying-in hospital, in labor of her second 
child. On visiting her at two o'clock, A. M., she was found to be 
suffering from an acute attack of pleuritis, with great general irri- 
tation and difficulty of breathing; her pulse was hard and full, and 
as frequent as one hundred and forty in the minute. On applying 



DIAGNOSIS. 27 

the stethoscope to the abdomen, the fetal heart's action was per- 
ceptible over a considerable space of it, extending across the whole 
hypogastric into the inferior part of the umbilical and lumbar re- 
gions, beating about one hundred and eighty in the minute. 

" The placental souffle was only audible at a small spot, in the 
left inguinal region, corresponding in frequency to the maternal 
pulse at the wrist. Having determined on bleeding the patient, 
I was anxious to observe what effect the sudden removal of blood 
would produce on the foetal circulation. When about eighteen 
ounces were abstracted, the mother's pulse became softer and more 
frequent, beating one hundred and ffty in a minute; and now the 
foetal heart's action also appeared full and strong, and came down 
to one hundred and fifty. The blood continued to flow, but not in 
so full a stream as I could have wished ; however, this could not 
be remedied, as the gentleman who operated found considerable 
difficulty in opening a vein. She experienced no relief from the 
pain and difficulty of breathing, until upwards of twenty ounces 
w^ere removed, when, although deliquium was not produced, yet 
the maternal pulse was much affected, rising to one hundred and 
seventy, but devoid of all that inflammatory character which it 
before evinced, being soft and weak. The arm was now tied up, 
and on applying the stethoscope again, to examine the foetal heart, 
it was found very sensibly altered; indeed, still quite distinct, and 
only beating ninety-two in the minute. Having kept my ear ap- 
plied to the cylinder for some minutes, during which time the 
patient was very low, although she had no actual syncope, I ob- 
served the foetal pulsation to vary; one minute being ninety-two, 
next rising to one hundred, and again to one hundred and twenty; 
and in this way it ranged for some minutes, until the patient had 
fully recovered from the effects of the bleeding, when her pulse 
descended to about one hundred and thirty, that of the foetus as- 
cending to one hundred and thirty-five. It now continued between 
this and one hundred. The number of beats varying every two 
or three minutes, for half an hour, when it ceased altogether. At 
9 P. M., the woman was delivered of a dead child, exhibiting a 
livid discoloration of the skin, like that of an individual drowned 
or hanged." 

This case by Dr. Kennedy, shows, I think conclusively, that 
the state of the circulation of the mother may exert a powerful 
influence upon the life of the child, and it might readily be con- 



28 DIAGNOSIS. 

ceived that sudden and great derangement of the maternal circu- 
lation would probably affect more injuriously the life of the foetus 
in utero, than would be the case should similar and equal derange- 
ments take place by slow degrees ; for it is very true that the life 
powers accommodate themselves to strange conditions, when they 
are brought about gradually, which they will in no instance sub- 
mit to if instantly or suddenly produced. In Dr. Kennedy's 
patient there was not only excessive derangement of the sanguine 
circulation, but there must have been considerable diminution of 
the functional force of the lung, brought about by the pleuritic 
inflammation, of which she was the subject; both of these circum- 
stances must be considered to have the power to modify the state 
of her blood as an oxygeniferous material. If to such circum- 
stances there should be superadded the almost total cessation of 
the innervative forces, coincident with the lypothymia of which he 
speaks, there is no reason to be astonished at the death of the 
child, or of the phenomena presented by it after its expulsion ; and 
*^ a livid discoloration of the skin like that of an individual drowned 
or hanged" is the sure evidence of its having perished by an 
asphyxia. The feeble source of oxygen supplied by its placenta 
became wholly insufficient to endow its blood with the requisite 
proportion of vital air, whence arose the unsteady action of the 
heart and its gradual decadence in force and frequency down to 
the last extinction of the beat. 

I remarked just now that an equal disorder of the blood as 
to its oxygeniferous qualities gradually brought about, is less 
likely to prove destructive to the infant in the womb, and I found 
this opinion upon the observation of several cases that have fallen 
under my clinical notice. I have the strongest impression of the 
case of a Mrs. Goodwin, who was under my care here a few years 
since, and who, laboring under an attack of laryngeal phthisis, 
suffered erosion or ulceration of the larynx to such an extent as 
to give rise to a most extraordinary emphysema, produced by the 
escape of air, in the act of expiration, into the cellular tissue 
outside of the ulcerated larynx; an emphysema so terrible that I 
found it expedient to make many punctures upon the thorax and 
also upon the wrists in order to dissipate the emphysematous in- 
flation. The patient, contrary to the expectation of all her friends, 
— in the extreraest emaciation — with the most distresssing dys- 
pnoea and cough, struggled against the causes of dissolution until 



DIAGNOSIS. 29 

the birth of her child, shortly after which she sunk and expired. 
I was amazed to find, upon the birth of the infant, that it was in 
the rudest possible health, and that it weighed in the scale up- 
wards of ten pounds avoirdupois — issuing into the world redolent 
of life, and escaping, as it were, from the sepulchral cavity of its 
dying mother's womb. 

I presume that no doubt can be entertained as to the fact that 
etherization, as a means employed for the diminution of the pains 
of labor, if carried to a certain extent, must modify the oxygenat- 
ing powers of the lung in respiration; that is to say, it can to a 
certain degree, and indeed it can totally, suspend the power of 
the lung to breathe upon the blood and endow it with oxygen. For 
my part, I cannot conceive that even slight suspension of the 
powers of the brain can be brought about by ether or chloroform 
without changing the hue of the arterial blood, giving it some- 
what the properties belonging to the venous side of the circuit. 

The numerous experiments that have been reported to the 
Royal Academy of Sciences, at Paris, particularly those of M. 
Flourens on various animals, and the still more numerous and 
various trials of ether and chloroform made and reported by Mr. 
Wackley, in the Lancet for Dec. 25, 1848, afford irrecusable 
proofs, that to continue the etherization up to a certain point, is to 
arrest the sources of innervations as to the par vagum. Such an 
arrest is death, for when the medulla oblongata, from which both 
the sensitive and motor cords of the pneumogastric take their 
origin, is suspended of its power by the influence of the ether, 
death must be the consequence, since, with the cessation of the 
respiration, there can be no further oxygenative process in the 
body, and the whole brain and all the sympathetic arches, all the 
ganglia and plexuses, must cease to exercise influence over parts of 
which they are the administrators, and for which they are the 
evolvers of life- action. I conceive, therefore, that every approxi- 
mation to such a condition as this exposes the foetus to great 
hazard, and however true it may be, that women do give birth to 
their children, being reduced to a state of insensibility under the 
influence of chloroform or ether, and yet the child may be not still- 
born, there is great risk that it will be still-born ; nor can statis- 
tics change the truth of the philosophical principle, which is not 
less true than the principle of gravitation, or the most fundamental 
dogma in mathematics. The inference which I should draw from 



30 NON-VIABILITY. 

these statements is, that in the use of chloroform or ether in labors, 
the practitioner should have constant reference to the influence 
which the etherization and chloroformization might possibly exert 
upon the child's circulation, because the child in labor is always 
more or less exposed to death from asphyxia, and more particu- 
larly in cases where an early crevasse of the ovum may have 
taken place. Nor can T readily understand the force of motives, 
that in a rapid and natural labor, should induce the physician to 
plunge the intellectual, co-ordinating and visual lobes into total 
oblivion with the mere intent to subduct a natural sensation of 
healthful pain; nor, much more, can I conceive how in a long, 
tedious, and painful labor, naturally dangerous to the child, he 
should venture to alter the blood of the mother — yea, for seventy 
hours as I have heard it has been done — and yet preserve that 
solemn respect for the rights of the infant committed to his care, 
which cannot but be, under such a treatment, greatly compro- 
mised. 

The foetus in utero is liable to be born in a state of non-viability 
from imperfection in its development, and possibly from imper- 
fections of its innervative operations ; or it may be still-born in 
consequence of a premature completion of development of certain 
parts. Its premature development, as affecting the anatomical 
characters of its heart, would be necessarily fatal, while an im- 
perfect state as to the progress of the transitive septum and arte- 
rious duct, offers equal obstacles to its continued existence. In 
like manner a certain degree of atelectasis pulmonum would pre- 
sent an insuperable obstacle to its duration, one which must be 
supposed of the foetus below the sixth month, notwithstanding 
the case of Fortunio Liceti, who was born at five and a half 
months and died past his seventy-ninth year. 

The placenta of the child is its branchial apparatus fulfilling 
ad interim the function to be afterwards delegated to its re- 
spiratory apparatus. In the tadpole there is a branchial organ 
of aeration to supply it during its larva life, but its gills dis- 
appear, giving place to its lung as soon as it is ready to quit the 
watery element : the placenta serves the same transitive state 
of life in the child. But it not unfrequently happens that in form- 
ing its mesenteric attachment in the early stage of uterine concep- 
tion, and in developing that mesenteric attachment during the 
subsequent stages of its uterine life, it shall do so inadequately, in- 



NON-VIABILITY. 31 

competently, imperfectly, and it may be that the child shall, not- 
withstanding such inadequacy or incompetency of its branchial 
apparatus, continue to develop itself up to a certain stage of its 
gestative existence, beyond which it can by no means continue 
to exist. I have seen many children born, that came into the 
world dead and putrid, without any causes that could with surety 
be referred to a status of its mother's health or conduct, and 
upon inquiry, after the labor, into the possible causes of its death, 
I have found the placenta manifestly too small to carry on the 
placental function of a fcEtus of such magnitude and volume. I 
have seen many other children born, who, in stature and in osseous 
proportion, generally had been w^ell developed, but who came 
greatly atrophied into the world, evidently in consequence of in- 
adequate magnitude of its placental mass. 

These, to be sure, are cases not subject to any but an ex post 
facto cognition by the medical attendant; nevertheless, it is proper 
to be aware of the morbific or destructive causes, since the candid 
explanation of them serves to protect the profession against re- 
proach for such events, and the parents themselves from painful 
misgivings as to their own bodily health and powers. 

Compression of the umbilical cord by cutting off the source of 
supply for the plasma nutritionis, and still more powerfully by 
obstructing the access of oxygen to the mass of the blood, is the 
cause of many fatalities to infants in the womb, whether in labor 
or before the attack of labor. I saw a beautiful child, the only 
hope of its parents, who never had another, evidently destroyed 
by a single knot upon its cord, so tightly drawn as effectually to 
preclude the oxygenation of its blood through the placental circula- 
tion. 

There is what is called non-viability of the child arising from 
causes connected with the rate of its development. For example : 
a child's heart might be developed so as to render it impossible 
to carry on the respiratory life, making it necessarily perish soon 
after its birth. A child born under my care, a few years since, 
came into the world at the full term of utero-gestation, and 
by a process of natural labor. It began to turn blue soon after 
birth ; to utter low moans like the voice of a kitten ; to breathe 
very irregularly and feebly, and evidently to die of cyanosis. The 
various remedies which I attempted had not the least effect in 
arresting the progress of its maladive condition. I observed that 



32 NON-VIABILITY. 

I could nowhere discover in its arms or legs an arterial pulse, 
which surprised me very much, for its heat was all the while 
maintained. Being surprised at the resistance of the case to the 
remedies which I had so often found effective to modify, if not to 
cure, the cyanosis neonati, I obtained permission of its friends to 
examine its thorax after its death. 

This child was found, upon examination, to have the heart of a 
reptile, which consists of a single ventricle and two auricles, so 
that, as in the chelonians, the blood is only partially sent to the 
lung, while a major part of it returns, as is observed by a dis- 
tinguished naturalist, to inundate the organs without having been 
subjected to the pulmonary action, and after having been mixed 
with the small portion of blood which had been subjected to aera- 
tion. The child with the heart of a reptile, is thus a non-viable 
child. 

A similar fatal result must ever attend the case of the child in 
whom the septum ventriculorum is but partially completed at the 
period of its birth, a case which has more than once fallen under 
my notice in children perishing by cyanosis. It is true, that a 
child born with an unclosed septum ventriculorum, — provided the 
aperture is not too large — may, for a certain length of time, con- 
tinue to carry on the pulmonary and systemic circulation, w^ithout 
much admixture of the blood on the two sides of the ventricular 
septum, and this must be plain, if we consider that the action of 
the two ventricles is both synchronous and symmetrical ; if the 
two ventricles should act asymmetrically, or in unequal times, 
then it would follow that the ventricle acting first, or with the 
greatest force, would press its fluid contents through the aperture 
of the ventricle acting later and with less force. But inasmuch 
as it is the generical law, that the two ventricles should act sym- 
metrically and synchronously, it is found — but very rarely, how- 
ever — that persons have attained a great age with an opening 
in the septum ventriculorum. 

Here is another cause of the non-viability of the child ; to wit, 
the premature reduction or obliteration of the area of Botalli's fora- 
men. If the child, in consequence of an extraordinary rapidity 
of development, should, some days previous to its birth, too con- 
siderably reduce, or entirely obliterate the foramen ovale, it would 
necessarily die of cyanosis for want of oxygen, because the blood, 
entering its venous system by the umbilical vein, could find no 



FORAMEN OVALE. ATELECTASIS. 33 

access to the systemic side of the circle, except through the pul- 
monary circulation, a thing not to be thought of in the unborn 
foetus in utero, and which, it may be said, is not competent to carry 
on the circulation of the whole mass of the blood. 

Billard, and other observers, have shown that the foramen ovale 
is open at birth, and that it is closed, in the major part of children, 
by the twentieth or twenty-iSfth day ; in a vast majority of them, 
much earlier than this; while in numerous samples, it is found to 
be patulous, although covered by its valve, to a late period in life. 
If the valve closes, it is as effectually shut for all the purposes of 
the circulation as if it were closed by the complete development 
of the septum auricularum, and an incalculable majority of the 
twenty-four millions per annum, that are born, do carry on the 
respiratory life without the least let or hindrance, although the fora- 
men ovale is certainly open in all of them as late as the third day. 
If the foramen ovale should, in a child, remain open much longer 
than in the average of cases, such a child might be deemed more 
obnoxious to the attack of cyanosis neonatorum; still a preter- 
naturally large aperture ought not to be deemed necessarily to 
involve the existence of symptoms of cyanosis, since the same 
synergic and synchronous law applies to the auricles as applies 
to the ventricles ; but if the innervation of the heart be asymme- 
trical in time or in force, then a greater energy of the right auricle 
could not fail to lift Botalli's valve, and while it would pour a part 
of its blood through the iter ad ventriculum dextrum, it could not 
fail to pour a large portion into the left auricle by lifting the valve, 
and, according to the intensity of the flow, fill the arterial side 
of the circle with venous blood. 

The child born at the fifth month or the sixth month of utero- 
gestation is nDn- viable, partly because its pulmonary vesicles, and, 
indeed, its whole pulmonary structure, is at that period incom- 
petent to the performance of its oxygenating function, and per- 
haps of its circulatory function. Mr. Hasse, in his Pathology, p. 
241, says that atelectasis of the lung ^^ consists in the imperfect 
expansion of the lung by the first inspirations after birth, that is, 
in a permanence of the foetal state, in the lung of the new-born 
infant." It is clear that such a condition of the lung implies the 
non-viability of the child, and it is equally clear that there are 
periods of the embryonal and foetal life, in which atelectasis is 
inseparable from such gestative stage of its existence. 
3 



34 ECTOPY. 

I have seen embryos of five months carrying on a sort of respira- 
tion for some time after their expulsion, but it is probable that only 
a small portion, if any, of the pulmonary vesicles could escape 
from the atelectasic condition natural to such an early date. Even 
were the pulmonary vesicles to prove dilatable at such a stage, it 
could not be supposed that the child should be viable, on account of 
the strong embryonal characters of the heart, which is certainly non- 
viable, because of the incompleteness of its septum auricularum, 
which in the earlier stages of embryonal life does not exist at all. 
Indeed, in the earliest stages of embryonal existence, the heart is 
a straight cylindrical tube, whose septa begin afterwards to be 
formed, and are not completed until the other developments are 
somewhat advanced : the septum ventriculorum is always com- 
pleted before the seventh month, whereas the septum auricularum 
is not complete until afterbirth — neonati always exhibiting, upon 
dissection, the remaining aperture of the foramen ovale. 

Imperfect developments in various parts of the child are some- 
times observed. A child born with an ectopy of the heart, or lung, 
or liver, maybe pronounced non-viable. A few^ years since I was 
called to see an infant at the village of Manayunk, in which I 
found nearly the whole of the intestinal canal contained within a 
great expansion of the abdominal extremity of the umbilical cord. 
As the umbilical cord is a caducous substance which must be 
separated from the living tissues in the course of from three to 
ten days, it is clear that such an immense examphalos could not 
be returned within the belly of the child not developed to receive 
it, and that it would be non-viable from such an ectopy. 

In January, 1848, I supervised the birth of a child, in which 
the whole liver was contained within the abdominal extremity of 
the umbilical cord, covered solely by a thickened position of perito- 
neum, and having an abdomen not sufficiently capacious to retain 
the liver within it, had it been possible to have returned it, which 
it was not, since the peritoneum was indissolubly united to the 
substance of the umbilical cord. 

Dr. Graetzer, in his work on the Diseases of the Foetus, p. 152, 
attributes foetal omphalocele to tractions made upon the navel by 
a cord rendered short by circumvolutions on the child's neck, or the 
slower and steadier tractions of a short cord. He appears to think 
that such efforts may give rise to a hernial sac within the abdo- 
minal extremity of the navel string. I cannot agree with the 



ACEPHALOUS FCETUS. 35 

learned author upon this point. He quotes Oken's Preisschrift 
iiber Entstehung and Heihing des Nabelbriicke to show that a 
foetal omphalocele may depend upon a fault of the development of 
the umbilical portion of the abdominal walls. 

In the earliest periods of embryonal life, the umbilical vesicle, 
or vitelline sac, is connected, not only by its omphalo-vitelline duct, 
but also by the omphalo-mesenteric artery and vein, with the intes- 
tinal tube, a knuckle of which is always, at that time, drawn up 
into the navel string, quite beyond and outside of the level of the 
belly. If any accidental adhesion, or any shortening of the vessels 
should detain the knuckle in the cord, it would necessarily consti- 
tute a case of omphalocele, and that would be to a considerable 
extent an irreducible hernia. Portions of contained intestine might 
perhaps be reduced within the belly, but not the whole contents 
of the omphalic sac. Hence there is little hope of saving the 
child's life, since at the fall of the cord, the intestine will be 
covered only with a portion of peritoneum. In all such cases, 
great care should be taken to cut the cord, and apply the ligature 
sufficiently far from the tumor, lest the gut itself should be 
opened; a case of which was recently related to Prof. Dunglison. 

Non-viability necessarily attends all the cases of acephalous and 
anencephalous foetus, and, as a general rule, it would be safe to 
pronounce that child non-viable, in which any degree of spina 
bifida should exist at the period of its birth. This statement is 
probably true, notwithstanding it is asserted that numerous chil- 
dren have been preserved, although born with spina bifida; it is 
as true as the statement that a six months' foetus is non-viable, 
while it is admitted that children have lived, that were born at 
the commencement of the sixth month. 

The astomatous foetus, the foetus that has been born with im- 
perfection of the anus, w^here the failure of the development 
affects a considerable part of the intestinum rectum, is non-via- 
ble-; as are those in w^hom the pulmonary artery springs from the 
left ventricle, while an aorta arises from the right. Persistence of 
the embryonal proportions of the ductus arteriosus will be fatal. 

Children in the womb are liable to various disorders that de- 
stroy them before birth. They are subject to encephalic maladies, 
and it is not a very rare event to meet with a hydrocephalic 
foetus whose head is so large as to render its transmission through 



36 DISEASES IN UTERO. 

the pelvis impossible, until the part has been diminished in size, 
by drawing off the water of a great hydrencephalic deposit. 

Children in utero are subject to retention of urine, and to dropsi- 
cal collections, rendering the belly too large to be delivered, until it 
shall have been tapped by the surgeon-accoucheur. These im- 
mense collections in the belly have been found in some instances 
to depend upon retentio urinse, revealed upon examination of the 
dead body of the foetus, in which an enormous bladder had filled 
up and distended the abdomen so completely, that it was impossi- 
ble for the child to be born until paracentesis had been effected. 

Children, doubtless, are still-born from apoplexy; they perish 
from hypertrophy, from atrophy, from various sanguine conges- 
tions and engorgements, interfering with the growth and develop- 
ment of their organs. Many children are destroyed in the womb 
by the detachment, accidental or spontaneous, of the placenta, 
cutting off, entirely or partially, the sources both of the plasma 
nutritionis, and of the oxygenating material. Children, also, are 
lost from forming knots on the cord, which being drawn tight, ob- 
struct the umbilical circulation. 

They are destroyed by the muscular action of the uterus. A 
primiparous woman, whose waters give way before the com- 
mencement of labor, and who, after a long and tedious labor, 
gives birth to her child, is more likely than not to find it still- 
born ; for, the child, under these circumstances, being subjected 
to the unmitigated pressure of the womb, without the intervening 
protection of the waters, must have its placenta so frequently, and 
for so long a time, compressed between the uterine paries and its 
body, as to suffer death from the suspension of the oxygenating 
process of its placental organ. 

There are many uteri to be met with, that refuse to yield to the 
distending force of the growing ovum, either on account of ex- 
cessive muscular irritability of the fundus and body of the organ, 
or from a non-conformable weakness and relaxation of the cer- 
vical and orificial portion of the uterine sac. Excessive develop- 
ment of the power of the fundus might well, in many women, 
result in the premature expulsion of the ovum ; and, too feeble an 
innervation of the retentive fibres of the organ, which are found 
at the cervix, would be sufficient to bring on the premature ex- 
pulsion of the embryo, or the foetus, under a true healthful irrita- 
tion of the expulsive portions of the womb. 



ACCIDENTS IN THE BIRTH. 37 

As soon as the act of expulsion of the head is complete, the 
medical attendant knows that the child which is about to come 
into the world, is living, by a certain feel of rigidity, or stiffness of 
the neck, though there is no absolute motion ; and he fears that it 
is dead, or in asphyxia, or in lypothymia, w^henever an utter re- 
laxation of the muscles of the neck permits the head to fall with- 
out any semblance of textural tension. In case a child's head is 
born under circumstances of a total absence of such textural 
tension of the neck, the attendant should make haste to free its 
body from its imprisonment within the organs, for the thorax still 
remaining compressed by the vagina and other parts that con- 
stringe it, there is little prospect that the first act of respiration 
will be performed, until the elastic force of the cartilages and bony 
thorax shall be set free from the influence of such pressure, and, 
by dilating the capacity of the thorax, fill the lungs with air, which, 
influencing the blood in the pulmonary capillaries, may serve to 
awaken the biotic force, by sending oxygen to the brain. It is 
true that the child, in many instances, makes its first aspiration 
before the delivery of the thorax, but it is not less true, that when 
the head is born, the pressure upon the thorax, or upon the trunk, 
is always partially relieved, and the elasticity of the trunk permits 
the air to enter the pulmonary vesicles, even before the diaphragm 
makes its first contraction. 

In most labors, the contraction of the uterus that serves to 
expel the pelvic extremity of the child from the cavity of the 
organ, condenses the placental superficies of the uterine surface 
sufficiently to displace a part, and often the whole, of the placenta ; 
and in all such cases that superficies is so greatly reduced in area, 
as effectually to preclude all idea of any valid performance of the 
placental function. Hence, it happens that, in all the cases where 
the head is the part last born, the child incurs considerable hazard 
from asphyxia; for, the branchial oflfice being suspended, and the 
mouth and nostrils as yet unexposed to the atmospheric air, any 
considerable delay in the delivery of the mouth and nostrils must 
coincide with the total suspension of the process of aerating the 
blood. 

The child may be apoplectic at its birth: it is apoplectic from 
injury done to it by the resistance of the bony parts of the pelvis, 
against which it has been impelled, and by pressure of instruments 
employed for its delivery, particularly where such instruments are 



38 ACCIDENTS IN THE BIRTH. 

inaptly adjusted to the surfaces of the child's cranium. Indenta- 
tions of the bones and fractures of them are not rare accidents ; 
accidents likely to be attended with extravasation or effusion. 

The medulla oblongata, or at least the spinal cord lodged in 
the three uppermost cervical vertebrse, must be, in some cases of 
extreme extension of the head in face presentations, dangerously 
compromised, or even destroyed. Slight shocks, or torsions, or 
compressions of this part of the nervous system, are likely to con- 
travene the power of the child to carry on the respiratory function. 
An apoplectic condition is threatened in all cases of the living 
fcEtus, in w^hich the head being already born, some deviation, 
some want of rotation, or some excessive proportion of the upper 
part of the trunk and shoulders, require long protracted efforts 
of the womb to expel the trunk into the world. In these cases 
of delay, the whole head of the child appears suffused with a 
dark purple circulation, becoming more and more intense in hue, 
in proportion to the length of the delay. But, it is reasonable to 
suppose, a priori, that this would be the case, since the head 
being entirely free from pressure, wMe the trunk and members 
remain under a pressure of many pounds, equal to the pressure of 
many atmospheres, great masses of the circulation should be 
driven qua data porta, that is to say, into the vessels of the freed 
head, whence it can with difficulty return into the trunk and mem- 
bers, compressed as they are by the vagina and other non-mus- 
cular tissues. Such an apoplexy, for the most part, is venous, 
and depends, probably, on a distension of the sinuses and venous 
apparatus of the brain, a condition, w^hich, when excessive, im- 
plies always a tendency to rupture of vessels and extravasation. 

The child is often born in a state of lypothymia, or fainting ; the 
body of the infant is here perfectly relaxed ; the surface is very 
pale; no muscular tension is observable in any part of the trunk, 
neck, or members; the diaphragm fails to move, and there are no 
signs of innervation, except the feeble beatings of the heart, per- 
ceptible at the umbilical cord, and by auscultation of the thorax. 

It is easy to distinguish between the apoplectic, the asphyxi- 
ated, and the syncopal condition of the child, and the treatment 
for each should be well considered. In the asphyxiated state of 
the child, artificial insufflation of the lung, and the frequent sud- 
den dash of cold fluids upon the face and breast, and stimulating 
and exciting slaps upon the buttock and thighs, may properly and 



APOPLEXY AND SVNCOPE. 3^ 

hopefully be had recourse to. In the apoplectical condition, an 
immediate section of the cord should be made, from the cut 
abdominal extremity of which the blood should be received into 
a tablespoon, until the sufficient abstraction of blood shall have 
served to relieve the engorged vessels of the encephalon. Such 
a process is unnecessary and improper in the asphyxiated condi- 
tion, in which a general livid hue of the child, accompanied with 
asphyxial relaxation of all muscular tension, and very faint and 
intermittent pulsation in the umbilical cord, serve as means of 
diagnostication. In the pallid, syncopal state of the new-born 
infant, gentle frictions, puffs of air into the face, the smoke of a 
burnt feather, volatiles held to the nose, and perfect rest in an ab- 
solutely horizontal position, are to be recommended. It would be 
as unreasonable in this form of syncope, to take a child into the 
lap, and hold it in the erect posture as it w^ould be to lift a faint- 
ing patient from the floor, and stand him on his feet, for there is 
this great difference between asphyxia and syncope, namely, that 
in asphyxia the vessels of the brain are well filled with blood, 
and the tension of the cerebral mass is not different, perhaps, from 
that of the highest health, whereas in lypothymia, the tension of 
the^cerebr^l mass is always below the par of health. In asphyxia, 
the vessels of the brain are occupied and distended with carbon- 
iferous blood, whereas in syncope, the vessels contain too small a 
proportion of blood of any kind. Blood loaded wdth carbon can 
by no means evolve in the brain the biotic force ; too small a quan- 
tity of blood in the brain is, in like manner, incapable of effect- 
ing that evolution. In the treatment of asphyxia, the object of 
the accoucheur should be to redden the blood, by promoting the 
act of respiration ; in the treatment of lypothymia his intention 
should be to direct a greater quantity of blood upon the brain, 
which he will scarcely effect, if he take the child from a recum- 
bency, or low horizontality, into a vertical or highly inclined pos- 
ture. 

I have already said that, in most labors, the placenta becomes 
detached either before or during the last contractions of the womb 
that effect the expulsion of the foetus from its capacity. In all 
cases of head presentation, this is to be deemed a fortunate event 
for the mother, for whom an early separation and extrusion of the 
secundines, are both a sign and a warrant of her safety; though 
it is indifferent as to the interests of the child. 



40 DANGER IN PELVIC PRESENTATIONS. 

Those labors in which the presentation implies that the head is 
to be the part latest to leave the capacity of the womb, are ha- 
zardous for the neonatus on this very account ; because, if, when 
the head is lodged in the vagina, outside of the circle of the os 
uteri, any delay in the completion of the birth should take place, 
the child incurs a risk, proportioned to such delay, of perishing 
with asphyxia; since it can receive no oxygen from the uterine 
surface of a detached placenta; — and since, indeed, the crushing 
and compressing effect of the uterine contractions on the branch- 
ial mass must as effectually, as even the complete detachment of 
it, preclude all processes of oxygenation through it. 

I make mention of this here, in order to justify my precept as 
to the management of such cases; a precept that I have not failed 
to inculcate in my lectures for several years past. The precept 
is this — videlicet, in all cases where the head is the last to be ex- 
pelled, the accoucheur ought to provide himself with a light and 
convenient obstetric forceps with which to extricate the head from 
its dangerous detention in case of delay.- 

It has been supposed that one child in seven has perished from 
the pelvic presentation, and though M. Paul Dubois avers, {vide 
Cazeaux, p. 359,) that only one in eleven pelvic, whereas only 
one in fifty cephalic presentations is lost, if we take into the ac- 
count all the cases where the head is last born, we shall discover 
a much greater proportion of fatalities. 

It is now many years since, that, induced by the loss of a child 
in pelvic labor, which I could have readily saved by the forceps, 
I resolved never to omit having the instrument at hand in such 
cases ; and I am very fully convinced that the loss of children in 
all labors in which the head is latest to be expelled, is not in my 
hands greater than one in eighteen, or one in twenty; and I 
fully believe that the mere precaution of providing for the exi- 
gency by having the forceps at hand, will enable any accoucheur 
of moderate skill greatly to lessen the distressing proportions of 
fatalities in his practice. 

Doubtless, in many such labors, the child is lost by too anxious 
a desire to hasten its deliverance, prompting the attendant to ex- 
cessive traction by the neck. An accoucheur will trust himself 
to pull with a degree of violence that would fill him with horror, 
should any equal force be applied to an infant lying in the nurse's 
arms and dressed. A tractile force equal to eight pounds, ap- 



STILL-BORN. 41 

pears to me to be a very dangerous one, and I think it must be 
evidently dangerous, if we reflect upon this, namely, that to lift 
up a child by two hands, placed, one on each side of the head, to 
"see London," as it is called, is a dangerous amusement; but, a 
child of eight pounds held up in this way, will have a tractile force 
not exceeding some five and a half to six pounds exerted on its neck, 
by the weight of the body and limbs. To pull at the neck of an 
undelivered foetus in the pelvic presentation, with a force equal to 
six or seven pounds, therefore, would be to go as far as pru- 
dence allows. With the light forceps of Prof. Davis, which is 
easily adjusted to the head, in the pelvic presentations, one may 
readily employ a much greater force without fear or hesitation. 
Hence, I venture to recommend that precautions against the dan- 
gers arising from separation or compression of the placenta in 
such cases, be invariably taken by preparing, and having at hand 
the forceps, which it might be too late to procure by a five mi- 
nutes' w^alk. 

Having thus expressed my opinion as to the precautions re- 
quired in all pelvic presentations, and others, in which the child 
is last to be born, I proceed to say that when the child, after its 
expulsion, lies still without breathing, but with a pulsating cord, 
it is to be held that the respiratory innervation has failed, and that 
the fault resides in some obstruction or failure as to the medulla 
oblongata, which is the respiratory portion of the brain, and not 
elsewhere. I repeat that, in such cases, w^e are to look to the state 
of the medulla oblongata, and considering that as the suffering 
point, direct all our resources towards the re-installation of its 
powers, seeing that if it be re-established in its full force, it alone 
is capable of recalling the other portions of the nervous mass to 
their healthful condition, and so as to all the dependencies of the 
nervous mass. 

Whatever may serve to produce sensitive activity in the me- 
dulla oblongata, is calculated to excite the motor cords that take 
their rise from it. Its sensitive cords are often quick with life, 
while its motor fibrils are inapt and dull as to their duty. To 
impress any one of the departments that are under the direct con- 
trol of the system of innervations, is to arouse the motor force for 
all of them. Then, as the nerves of physiognomical expression, 
have the same origin as those of the respiration, to awaken the 
motor power of one, is to set on foot that of the other. Hence, 



42 STILL-BORN. 

to stoop and puff the breath very suddenly, upon the face of the 
child, to^ sprinkle it with brandy, or with water, to irritate its nos- 
tril, to pour from a height, a stream of cold spirit upon its breast, 
to slap its buttock with the hand, to irritate the muscular dia- 
phragm by frictions with the open palm, is, in numberless in- 
stances, to awaken the movement force, and establish it, which, 
without such measures, w^ould probably pass into a deeper and 
fatal anaesthesia of this vital tie, this noeud-vital, to use M. Flou- 
ren's beautiful mot. 

In cases where these external measures fail, the declining tem- 
perature must be maintained by the warm bath, which may be 
rendered stimulating by the addition of brandy ; which allows 
time for the further application of such agents, as may serve to 
rouse into activity the torpid sources of the pneumogastric nerves. 
It is worthy of remark, that the late Dr. Dewees was from much 
experience of cases, more inclined to the employment of dry 
heat and frictions, than that of the bath. I have the greatest re- 
spect for the practical precepts of that distinguished physician, 
but I cannot on that account hesitate to remark that the use of the 
bath is far more convenient than that of dry frictions, since the 
form and smallness of a new-born child, make it very difficult and 
awkward to employ frictions ; whereas the bath, rendered excit- 
ing by spirit, or wine, or mustard, is quite free from any objec- 
tion of its inconveniency. A light electro-galvanic battery, if at 
hand, might be profitably employed to institute the first contrac- 
tions of the diaphragm, that are alone required to charge the blood 
of the pulmonary capillaries with oxygen, which, once in the 
brain, immediately sets free the hitherto torpid biotic powers of 
the medulla oblongata. I have no clinical experience of my own 
to cite in favor of such a recourse, because, when I have made use 
of the battery for this end, so great delay has occurred in the 
preparation of it, that life was wholly extinct before it could be 
brought to act upon the infant. Sutton's light and convenient 
apparatus could be readily, in all suspected cases, be placed in 
proper activity in an adjoining apartment; and, doubtless, such 
a good precaution would be followed by some degree of success, 
otherwise unattainable. Sutton's battery is contained in a small 
box, and can be very easily transported to any point at which it 
might be deemed likely to be wanted. Shocks from such a bat- 
tery passing from the vertex to the umbilicus, or transversely 



THE CORD. 43^ 

through the lower margin of the thorax, might set the machinery 
of the respiration in motion, and thus move the entire train of the 
innervative forces. 

The remainder of the umbilical cord of the child is cast off, 
being separated from the living surfaces by a process of absorp- 
tion, or of sloughings which are virtually absorptions. The cord 
dies, — it becomes perfectly dry, and of a crisp or corneous hard- 
ness. 

As the cord contains two umbilical arteries, and an umbilical 
vein, surrounded by a magma of tissue enclosing a fluid, which is 
called the Whartonian jelly, it follows that the liquid part of this 
jelly must escape from the cord by a process of exosmose, and 
in proportion to the mass of the cord, will, perhaps, be the time 
required for the complete separation of the fluid contents of the 
umbilicus, and its exsiccation. There are some specimens of the 
nmbilical cord w^hich are not much larger than a swan quill, while 
others are as big as one's thumb ; it might naturally be expected 
that a heavy, large stout cord might require a longer time to effect 
its separation, than a small, delicate one, since the perfect exsic- 
cation of a large portion of it must be effected before the fall. There 
are many specimens of cords that are found to be entirely detached 
before the end of the third day, w^hereas some retain their con- 
nection with the living surfaces as late as the tenth or even the 
twelfth day ; for the most part, I think that the cord falls some- 
where between the fifth and the seventh day. 

It is two arteries and one vein that must be detached in this 
case, and doubtless there will be met with considerable variety 
in the strength and vigor of these vessels ; very powerful and 
vigorous umbilical arteries will probably have much stouter and 
heavier elastic coats, than smaller and more delicate ones, and 
longer time will be required for their detachment. 

A ligature put upon the umbilical cord, before the severing of 
the child, does not always put an immediate stop to the pulsation 
in the abdominal extremity of the vessels, and in some instances 
the effect of the heart's systole is felt up to the ligature for a long 
time after the cord's severance : for the most part, however, the 
pulsation soon ceases, and the elastic coat of the vessels reduces 
the calibre to its minimum diameter. Sometimes a small portion 
of coagulated blood is found in the dried tubes, after the fall of 
the cord, when all vitality as to the vasa vasorum of the vessels 



44 FORMATION OF THE NAVEL. 

being at an end, the living absorbents cut them off at the level of 
the umbilicus, which in foetuses is always protuberant, always 
projecting beyond the general level of the belly. The process of 
separation may be observed to begin upon the circumference of 
the umbilicus, where the amniotic coat of the cord comes in con- 
tact with the dermal surface, and a raw superficies is visible at 
the point at which the detachment takes place. 

An artery cut off by a knife, is invariably retracted in con- 
sequence of the elasticity of its coats ; and the retraction of the 
umbilical vessels within the belly has the effect of drawing the 
navel inwards, and converting it into a dimple, instead of leaving 
it protuberant as it was before the birth of the child and the fall 
of the cord; if the contraction is very powerful, the dimple of the 
navel becomes very deep, and the deepest part of the navel is that 
which looks downwards towards the bladder. There is also a 
degree, but a less degree of contraction in the remainder of the 
umbilical vein, which passes along the falciform ligament of the 
liver to enter the portal vein, and hence we see a kind of cushion 
in the upper half of the dimple of the navel. 

This retraction of the umbilicus is an economical process, by 
means of which the raw and exposed surface left by the detach- 
ment of the cord is greatly diminished in its superficies, and there- 
fore requires a much shorter process of healing. Indeed, in some 
specimens, it appears to be healed almost as soon as the cord falls. 
It sometimes happens that the retraction of the artery and vein 
being imperfect and incomplete, the child is found to have a pro- 
tuberant navel, which excites suspicion on the part of the mother, 
that all is not well; and indeed, all is not well, for, inasmuch as the 
retraction of the surfaces has not taken place, the umbilical ring 
remains imperfectly closed, and there is a constant tendency on 
the part of the omentum or of a knuckle of intestine to engage in 
the dilated ring, thus furnishing a physical obstruction to its perfect 
contraction or closure, and thereby exposing the child, in the 
morning of its life, to the attack of a troublesome and dangerous 
examphalos. 

It is plain, if this statement be correct, and I doubt not that it 
is correct, since it is the explanation of Billard, that admirable 
Frenchman, whose early loss was deplored by every friend of 
science, — it is clear that the attentive physician ought to take 
all necessary precautions to promote the retraction of the um- 



FORMATION OF THE NAVEL. 45 

bilical arteries and vein; he should not prevent the naonthly nurse 
from using a proper compress, of sufficient strength and thickness, 
to oppose the action of those causes, that would tend to drive the 
umbilicus outwards, nor ought he, from some erroneous notion 
of the uses of the bandage, to direct the swathing of the child to 
be discontinued before the end of the month. If, at the end of 
that time, the umbilicus be found to be very deep and very perfect, 
there is probably no further necessity for the employment of the 
belly band ; but, the use of the band should not be dispensed 
with, in any case, as long as any protrusion or disposition to pro- 
trusion is found to remain. 

The cord is generally cut off even with the dermal level, which, 
as I have already said, is then retracted to make the umbilical dim- 
ple. Occasionally, however, and not very unfrequently, it sepa- 
rates further off than the dermal level, leaving a button-like remain- 
der, a sort of bunch of granulations as big as the head of a diaper 
pin, sometimes as big as a small pea, and very rarely not less than 
half an inch long, and which can never heal ; for it is incapable 
of healing, as it can form no dermoid nor epithelial surface. I 
have seen one unhealed at the twenty-second year of a young 
man's age. This accident depends, probably, upon this, namely, 
that the vasa vasorum of one or both of the umbilical arteries do 
not perish quite down to the dermal level ; and being cut off by the 
absorbent vessels at too great a distance from the surface, they 
cannot clothe themselves with a true scarf skin, and therefore can- 
not heal. This discovery is not often made until the end of the 
month, or until the fifth or sixth week of the life of the child, when 
it excites a natural alarm in the tender bosom of the parent, who 
never fails to attribute it to the fault of the doctor in tying the 
cord, or to the carelessness of the nurse in dressing it, whereas the 
fault is to be laid at the door of the vasa vasorum, whose pertina- 
cious vitality has compelled the absorbents to cut them off too far 
outside. 

This little tubercle of granulations grows from a very narrow 
peduncle or footstalk, and doubtless it might be twisted off with a 
pair of dressing forceps without the slightest injury; but one does 
not like to do violence to a young baby, and one is liable to re- 
flect that the canal of the arteries might remain patulous at that 
late period of life. Let it be surrounded with a waxed silk thread, 



46 INFLAMMATION OF THE NAVEL. 

tied tightly, and it will probably fall off on the succeeding day; 
after which it gives no further trouble. 

In some children, the surfaces from which the umbilical cord is 
detached, are affected with ulcerative inflammation; when, a hard, 
swollen, red base being fully formed, the ulcerative process is 
likely to continue until the basis on which it sits is cured of its in- 
flammation. It is as unreasonable to expect to heal such an ulcer 
until the base has first begun to recover, as it would be to heal an 
open cancer seated upon a carcinomatous base before that carci- 
nomatous base is removed. Now and then it happens that the in- 
flamed areola becomes avast area, spreading over almost the whole 
abdomen of the child, invading at least, the whole of its umbilical 
region, under which circumstances the most violent erysipelas 
seizes upon the tissues and extends down to the genital organs, 
or rambles over other parts of the child, until it perishes miserably, 
from a copious, sanious and bloody discharge constantly flowing 
from the surfaces of ulceration. The new^ born child, in whom 
inflammation seizes upon the circumference of its umbilicus, is in 
danger, and should receive the careful attention of the physician. 
This occurrence, being out of the common order of events in 
the lying-in chamber, is apt to be misconstrued, and places the 
medical man in a false position of unjust imputation or innuendo; 
let him therefore be careful to make an explanation of the circum- 
stances, so as to defend, not only himself, but his class, from un- 
just accusations. Probably the best mode of treatment in such 
cases, is to cover the inflamed part with pledgets of lint dipped in 
cold infusion of flaxseed or slippery elm, after taking the pre- 
caution to circumscribe the augmenting area of inflammation by 
producing a new and different irritation, in drawing around it the 
point of the nitrate pencil. The inflammation produced by the 
point of a nitrate of silver pencil drawn around and outside the cir- 
cle of inflammation, preoccupies the tissue involved, preventing, by 
its occupation or prepossession, the extension of the primal malady 
beyond the limits thus assigned and circumscribed. A leech or two, 
placed upon the white tissue, and never upon the red tissue, might 
favorably incline the diseased parts to recover through the process 
of resolution of inflammation, but if they cannot recover by resolu- 
tion, and can be prevented from spreading over the whole umbilical 
region by the method of circumscription already mentioned, then 
there may be time to wait until the process of ulcerative suppura- 



IXFLAMMATION OF THE NAVEL. THE MECONIUM. 47 

tion shall disengorge the inflamed tissues, so that when the in- 
flamed base is healed, the ulcer may be cicatrized. I have seen 
several deaths from this cause; and my friend Dr. Rutter, of the 
district of Southwark, has observed many children to perish from 
erysipelatous inflammation commencing at the umbilicus, in the 
disastrous epidemic of puerperal peritonitis, which he witnessed 
in that district. 

The new born child generally comes into the world with its 
large intestine loaded with a dark, viscous, adhesive substance, 
called meconium, which may be found in the intestines very early. 
I have found it as early as the fifth month of foetal life; it 
is probably the stercoraceous product of a gastro-intestinal diges- 
tion of mucous, of muco-albuminous and bilious deposits in 
the alimentary tube of the embryo or foetus. The quantity is 
sometimes very great, and the intestine so loaded with it, that when 
the child is born, the peristaltic power not being called into action, 
the infant seems to suffer irritation from its presence. It is thought, 
and it is very probable, that when the quantity is very great, and 
the substance extremely viscid and adhesive in its consistence, 
the child shall feel pain, which is called griping, from irregular 
and spasmodic attempts of the peristaltic muscles to move it off 
the mucous surface. It is, most evidently, quite reasonable to give 
some artificial aid to the bowels by the injection of water or muci- 
lage, pure, or rendered more exciting by the addition of small 
quantities of salt, or oil, or molasses, or a mixture of all three ; or 
chamomile tea, with a little castor oil, may be used as the enema. 
For the most part, in this country, a child in whom the meconium 
does not come off, is compelled to swallow castor oil, of which 
the quantity usually given is a small teaspoonful, which is more 
than is required for the occasion. Half a teaspoonful of fresh cas- 
tor oil, which is not rancid, should be thrown into a tea-cup con- 
taining some warm sweetened water, from which the globules 
should be skimmed off with a spoon, and given to the child until 
the whole quantity is taken. 

Where a child passes a whole day without having its first 
evacuation, it becomes the duty of the physician to inquire into 
the state of the rectum, in order to know whether it be subject 
to some iraperforation or congenital narrowness of the bowel or 
not. In the case of imperforation, if the absence of the bowel is 
not too complete, and if the upper segment of the intestine be 



48 IMPERFORATE, OR CONSTRICTED RECTUM. 

found a short distance of the anus, it is possible, and it has some- 
times been practised, to make a communication with the interior 
of the gut by a bistoury or trocar, but these operations mostly 
fail in the long run. Yet some have proved successful. 

In one case, that of a child, otherwise very perfect in its forma- 
tion, it was observed that no alvine dejections took place for the first 
two or three days after birth, the infant in the meantime taking 
food freely. "When it at length became affected with pain, I made 
an examination, and found the rectum so much contracted, that I 
could only introduce one of the smallest sized bougies, that are 
made of rolled linen, and that only after the most persevering at- 
tempts. I think that the intestine, for two or three inches, was not 
larger than the urethra of the child. I succeeded, after the most 
patient efforts, in conducting the point of the bougie into the more 
expanded portions of the gut, and upon w^ithdrawing it, perceived 
that it was followed by a small discharge of meconium. I carefully 
dilated the intestine with larger and larger cereoles, until the child 
being restored to health, I had no more occasion to see it. It 
afterwards died at an early age, of disease of the brain. 

It struck me, while attending this patient, that some of the 
cases of supposed imperforation, are only cases of congenital nar- 
rowness, and that a more careful examination might reveal to the 
surgeon the existence of a canal, which, without great care, might 
escape his observation, and I w^ould recommend that in all cases 
of suspected imperfection, this point should be settled before mak- 
ing any incision, or perforation with the trocar. In any such 
cases, it would be much preferable that the child should be cured 
by the dilatation of a natural passage, which, after the cure, leaves 
a natural surface, rather than it should be healed by incision with 
a bistoury or trocar, which could leave nothing but a cicatrized 
surface, and which, being unnatural, is always liable to disease. 



CAPUT SUCCEDANEUM. 49 



CHAPTER II. 

CAPUT SUCCEDANEUM. 

It happens, not unfrequently, that the child comes into the 
world with a swelling, and sometimes with two swellings, upon 
the head, which has received the appellation of caput succeda- 
neum, or substitute head. In most of these cases, the swelling 
is found upon the vertex; and, indeed, in primiparous labors, 
where there has been an early rupture of the ovum followed by 
a reluctant dilatation of the os uteri, it will be found generally, 
that considerable effusion and engorgement in the scalp covering 
the vertex, are present : this swelling usually disappears, I think, 
within some twelve hours after the delivery; but, occasionally, 
the effusion continues to take place until a very considerable, 
elevated, fluctuating tumor becomes completely formed. 

I have never seen an infant born with this fluctuating tumor, 
though I have met with a great number of them in which the 
fluctuating swelling has been discovered by the end of the first 
day. This constitutes caput succedaneum. 

Prof. Froriep, in his Handhuch der Geburtshiilfe, sec. 328, tells 
us that this tumor, which the Germans call blutbeulen and 
kopfblutgeschwulst, appears in from twenty-four to forty-eight 
hours after the termination of the labor. 

I have met with several samples of the affection in which a 
caput succedaneum occupied each of the parietal regions, making 
two distinct fluctuating tumors, one on the right and the other upon 
the left parietal protuberance, and having no connection with each 
other. 

Froriep remarks, very correctly, that the swelling is neither 
hot, nor painful, nor red. It appears to consist of a watery blood 
that does not coagulate, and that is removed by the absorbents 
without evincing any tendency to suppuration. It is a mere 
ecchymoma or ecchymosis from pressure. There is this very 
singular circumstance, that it manifests itself so long after the 
accidental cause of it; which maybe explained, perhaps, by sup- 
4 



50 CAPUT SUCCEDANEUM. 

posing that a bloody serum continuing to ooze into the seat of the 
ecchymoma, comes at last to form a soft fluctuating lump as large 
or larger than half an egg. The margin of this tumor feels as if 
the cranium were wanting, so sharp and precipitous is the limitary 
edge of the circumscribed cavity, containing the blood. Ecchy- 
moma capitis may be correctly defined as a circumscribed cavity 
containing bloody serum ; in which it differs from abscess, which 
is a circumscribed cavity containing pus. 

Among the numerous examples that have fallen under my no- 
tice in thirty years, two only have ended in suppuration. One of 
these was of enormous size, covering the entire crown — it was 
discharged by the point of a lancet — but the operation was deferred 
so long, that the child afterwards sunk under the excessive and 
protracted irritation. The other child recovered. 

1 believe that the rule should be, to refrain from opening the 
cavity, and rather, to wait for the absorption of the fluid, which 
being done, the scalp is observed to have recovered its healthy 
elasticity and tone. 

Perhaps no therapeutical treatment is really requisite ; but as 
I have for so many years, and in such very numerous instances, 
been accustomed to follow a routine of treatment, I do not feel 
justified, after a long success, in la3'ing it aside. 

My custom is to cover the swelling with a cataplasm that is 
w^orn under the cap, which holds it well in place. 

The cataplasm is composed of a very thin or difi[luent poultice 
of crumbs of bread boiled in milk^to be afterwards thickened with 
the petals of chamomile — stirred in while the poultice is hot, and 
in quantity enough to give it a proper pultaceous consistence. 

The poultice is usually worn by my patient until the absorption 
is completed. 

I have, among others, the following motive for using the cha- 
momile poultice ; namely, the child does not suffer from any 
eczematous tendency, that generally manifests itself under the 
simple bread poultice, when long worn. 

I believe that a caput succedaneura, not excessively large, will 
generally disappear in the third week. 

I suppose that to puncture and evacuate the cavity, might lead 
to an earlier and less troublesome cure — but it is also to be pre- 
sumed that the puncture exposes the scalp to a risk of erysipelatous 
or suppurative inflammation — I, therefore, respectfully advise the 



INFLAMMATION OF THE EYES. 51 

safer plan of trusting the cure to the absorbents ; the more con- 
fidently, inasmuch as, in the majority of my cases, I have found 
every vestige of the accident to disappear by the tv^enty-first day, 
while only a few have lingered as long as the thirtieth day. 



CHAPTER III. 

INFLAMMATION OF THE EYES. 

It is very common to observe in the neonate, one or both eyes 
to become inflamed within twenty-four hours after the delivery. 
In a multitude of such cases, the trouble arises merely from a 
slight inflammatory engorgement of the conjunctive coat of the 
lid, which sometimes, how^ever, extends to the orifices, and per- 
haps to the excretory ducts, of the Meibomian glands. The simple 
and slighter forms of the malady are usually treated, and found 
readily curable, by frequent bathings with warm milk and water, 
and pretty generally by spirting the mother's milk, from the nip- 
ple itself, into the eyes. Such bathings, for which, in this quarter, 
an ordinary and good substitute is found in the mucilage of sas- 
safras-pith, suffice for a major part of the cases. 

Those examples, however, that do not readily yield to so 
domestic a medication, require the attention of the physician, 
who, upon separating the lids, is often surprised to discover a jet 
of pus to issue from between them. To discover such a jet of 
pus is to become aware of very considerable alteration in the 
histological state of the conjunctiva, which, by force of inflamma- 
tion, has now become converted from a mucogenic to a pyogenic 
membrane or tissue, a condition that is likely to extend itself by 
invading all the congenerous textures. It is, therefore, important 
to secure an early recovery. 

If the lower lid be pulled downwards, and very slightly everted, 
so as to enable the observer to see the state of the palpebral 
conjunctiva with a lens, it will be found to have become finely 
granular ; or in, other words, to have lost a part or the major part 
of its epithelial covering, whence arises its faculty of excreting 



52 INFLAMMATION OF THE EYES. 

pus instead of mucus, which alone it would produce while in a 
natural and healthy condition. 

The secretion from the granular surface is, in some of the 
examples, very abundant; so much so, that repeatedly during 
each day, there collects beneath the closed palpebrse a quantity 
of pus, sufficient to constitute a fluctuating tumor which is a 
true abscess — for it is a "circumscribed cavity containing pus," 
the cavity consisting of the whole conjunctiva, closed by the firm 
apposition of the upper and lower palpebrae. — When the surgeon 
opens the eye, the cavity is opened and emptied, but immediately 
commences to fill again by the firm closure of the tarsal edges. 

All persons, nearly, who have conjunctivitis, even very slight 
attacks, have a coincident intolerance of light; and the young 
infant, like older patients, appears to suffer distress when too much 
light is admitted into the room. Hence, among other items of 
treatment, an important one consists in a correct gauge of light 
for the patient. It does not seem to me that black darkness is 
requisite, but that a dim and obscure chamber should be chosen. 

It is clear, from this representation, that, in addition to the care 
as to the intenseness of the light admitted, one should observe 
constant precautions as to the virtual conjunctival abscess, which 
ought to be opened and discharged many times a day by sepa- 
rating the lids. This precept is certainly worth attention, for it 
is extremely common to find that the pus is not discharged from 
the conjunctival sac, for many consecutive hours, by the nurses or 
managers of the little patient: and it is quite certain, that, to allow 
the whole front of the globe with its transparent cornea to swim in 
a thick purulent lotion for hours together, is to invite the extension 
of the granulating process to the corneal conjunctiva itself. 

To cleanse the eye, nothing is so convenient or w^ell adapted 
as a bit of fine sponge, which picks up the fluids, while a piece of 
rag slides over them. The sponge ought to be applied many 
times a day, and that, with a gentle pressure, sufficiently firm, 
however, to press out the fluids from between the margins of the 
lids. 

In very young infants, the inflammation extends, in some of 
them, through the substance of the palpebral to the corpus mu- 
cosum of the lid, which is thus inflamed through and through, 
and becomes greatly thickened ; indeed, so much thickened as 
to make it quite impossible to obtain a view of the cornea. 



INFLAMMATION OF THE EYES. 53 

Under these circumstances, a very good dressing is had by 
keeping the lids covered with pledgets dipped in cold water, 
or cool flaxseed, sassafras, or slippery-elm mucilage, carefully 
strained. 

As a collyrium, I beg leave to recommend the following formula 
for one that I have been accustomed to prescribe for many years. 
Take of acetate of zinc, two grains; of wine of opium, twenty 
drops ; of rose w^ater, one ounce ; to make a collyrium. Pledgets 
moistened w^th this collyrium may be kept upon the closed lids, 
and occasionally, upon depressing the lower lid, the slightly ex- 
posed or everted conjunctiva and tarsal border should be touched 
b}' the sweep of a camel hair pencil, dipped in the liquid. 

Where this does not very soon introduce signs of amendment, 
the camel hair pencil should be dipped in a solution of nitrate of 
silver, two to four grains to the ounce, with which the lower lid, 
everted, ought to be suddenly swept; an instantaneous contact 
only being required. As soon as the lids close, the rolling of the 
ball serves to make the rest of the application. This plan is 
equally efficacious with that of dropping the solution into the eye, 
and far less painful. 

Leeches are sometimes required, as w^ell as blisters, to the mas- 
toid spaces,- or to the nucha — but these are very painful remedies, 
that are rather to be eschewed, if possible. 

I am not waiting a treatise upon ophthalmology, and shall not, 
therefore, give any greater extension to these remarks, which re- 
late rather to a very common specialty in the practice of the ac- 
coucheur, than to the ordinary business of the oculist and oph- 
thalmologist. I shall merely add, that the young practitioner 
ought to be always watchful of the earhest opportunity to ascer- 
tain the state of the cornea in these cases of infantile conjunctivitis 
and psorophthalmy — in order that he might be able to take the 
wisest precautions against the progress of ulcerations, or intense 
vascular injections of the corneal conjunctiva that might end in a 
glaucoma, or some still more disastrous result of such inflamma- 
tions. 

SORE MOUTH. 

When a young child is put into the hands of a monthly nurse, 
she is sure to expect that her nursling wiir have, within the 



54 SORE MOUTH. 

month, and generally within the first fortnight, an attack of chil- 
dren's sore mouth, commonly known as aphthae. 

The quite general expectation of such an occurrence, enter- 
tained by nurses and experienced women, shows that young 
children are very liable to the disorder in question, nor is there 
any great reason to be surprised, that parts so tender and delicate 
in their structure, should become inflamed very soon after the 
first application of them to the purpose of sucking. Indeed, the 
suction power of a young child is so strong as most frequently to 
produce some degree of inflammation in the mother's nipple, and, 
in many instances, to inflame it so severely as to cause painful 
ulceration. The same force that is employed to blister, to in- 
flame or ulcerate the nipple, is equal to the development of a cer- 
tain degree of inflammation of the mouth of the child ; for, in em- 
ploying the force, it is decomposed, one half of it being exerted 
on the nipple, and the other half on the mouth of the child. 
Hence, when we hear of a child's sore mouth, we are almost sure 
to hear of a mother's sore nipple, and vice versa, for they mu- 
tually hurt each other; hence, also, the general opinion that the 
child's sore mouth is contagious, whereas it is merely mutual as 
betwixt the nipple and the mouth. 

There are various grades of the stomatitis of children. It may 
be a mere erythema of the corpus mucosum, unattended with the 
formation of the little pustules or bullae, which, when they break, 
leave a raw surface upon the general inflamed base. This stoma- 
titis erythematica is characterized by diflfused redness and dry- 
ness of the mucous membrane of the lips, gums, tongue, cheeks, 
and palate, which have become the permanent seats of a san- 
guine affluxion determined to them by the act of sucking, which 
is not unlike that of the cupping glass. 

In this condition, the surfaces look not only dry, but somewhat 
smooth and shining — and are evidently a little painful at the first 
attempts to draw the breast, but become less so as soon as they 
are fully moistened and lubricated by the inflowing milk, saliva, 
and mucus, with which the whole mouth is bathed as soon as 
the action commences. 

Whenever this redness acquires a certain intensity, the inflam- 
matory action has reached a stage in which small portions of 
coagulating lymph are excreted, and remain here and there at- 
tached to the membrane, presenting the appearance of whitish 



SORE MOUTH. 55 

specks or sloughs. If removed by wiping them off with a hand- 
kerchief, they are mostly found to leave no little ulcer beneath — 
yet sometimes when thus taken off, there is evidently a small pit 
beneath them. 

These deposits of lymph are, I presume, identical in character 
with the lymph deposits that are seen on the throat and palate in 
croup and in scarlet fever, and on the whole buccal and palatine 
mucous surfaces in some cases of mercurial ptyalism. 

Some of the spots consist of very small vesicles filled with a 
coagulated albumen, or perhaps with lymph — which is contained 
beneath an epithelial capsule or covering; and which cannot be 
wiped off with a handkerchief or linen rag, until after the capsule 
has been broken open. Now and then the capsules, and even the 
uncovered lymph or fibrinous deposits, are observed of an ashen 
hue — or they may be seen to turn of a drab or black color, 
owing probably to the mixture of a small portion of blood-discs 
that have escaped together with the other inflammatory products, 
and which, by their presence, indicate a very high degree of 
inflammatory action. 

It is common among practitioners to attribute the sore mouth 
to a faulty condition of the primse vise, consisting of an acid or 
mucous-saburral state of those organs. There is little reason to 
doubt that an unhealthy state of the digestive organs may intro- 
duce an irritable condition of the mouth and fauces, and thus 
give rise to a greater disposition in the parts to inflame under 
the cupping action of the mouth in sucking — but very certainly, 
we meet with numerous examples of aphthous children in whom 
the health of the stomach and bowels continues to be perfectly 
good, and who, therefore, do not require any doses of physic. 

The slighter cases of aphthaB are treated by cleanliness — which 
means, by washing the mouth carefully with a linen rag dipped 
in cold water, so as to remove all remnants of milk, that, by fer- 
menting in the mouth, might add to the erythematous propensity. 
It is common also to rinse the mouth with borax water — or to 
sprinkle upon the tongue a small pinch of pulverized borax and 
sugar. 

A teaspoonful of honey of roses, to which may be added a 
tablespoonful of water and a pinch of alum or borax, is a conve- 
nient and useful remedy, as is also a little weak lime-water; and 
especially a mixture composed of one drachm of Peruvian bark 



56 SORE MOUTH. 

powder, and a gill of lime-water — which often removes the dis- 
order very speedily, if used as a wash for the mouth. 

In bad cases, recourse ought to be had to the antiphlogistic 
powers of the argentum nitratum, of which a solution, consisting 
of a grain of the nitrate to one ounce of distilled water, may be 
very safely and usefully applied to the diseased surfaces with a 
throat-brush — a large camel-hair pencil. 

The constitutional disorders which accompany some of the 
cases, require their appropriate treatment, which is various as the 
stages and differences of those constitutional maladies. 

For example, fever, or chronic diarrhoea and dysentery, long 
and protracted bronchial catarrhs, each will require the course of 
treatment appropriate to it, in order to remove the sore mouth, 
which, under such circumstances, is rather an epi-phenomenon, 
than a primary affection. Perhaps, it may be deemed advisable 
in all the cases, to exhibit small aperient doses of an antacid me- 
dicine, such as magnesia, infusion of rhubarb mixed with lime 
water, or even, in certain instances, very small doses of hydrarg. 
cum creta. But all these doses should be held in reserve for the 
actually necessary demands of the patient; and they should not 
be given unless most clearly indicated by the wants of the case. 

The kind of sore mouth called by the French writers muguet, 
is asserted to be a vegetable or sporiferous substance, developed 
upon the mucous membrane of the mouth. It is distinguishable 
from aphthae by its conical form, and by its being uncovered by 
any capsule of epithelium. It is a collection of vegetable spores, 
(Sporotrychium,) which fall off in the course of four days. 



CORVZA. 57 



CHAPTER IV. 

CORYZA. 

The faculties of a young child are merely instinctive, not ra- 
tional, nor intelligent. 

"While its instinctive sense suffices for its wants, the child is 
\Yell ; but when circumstances call for the use of the reasoning 
faculties, in order to rescue it from any dangerous predicament, it 
is liable to perish, because it is incapable of reasoning, and can 
have no dependence save on its instinctive faculties and powers. 

Inasmuch as the act of respiration is one of the most important 
of the vital functions, it follows, that whatever may serve to con- 
travene it, tends to destroy the patient. This is clearly to be un- 
derstood, if it be admitted that the oxygenation of the tissues is 
indispensable to life, which cannot exist except in the presence 
of oxygen. 

The mouth and nostrils are the orifices, or stigmata, through 
which the vital air has access to the lungs, whence it is taken up 
by the blood, in order to be given out in the capillaries. 

In strictness, the nares are the respiratory stigmata, and an in- 
stinctive sense teaches the new-born child to use them alone. 
Hence, whatever causes serve to diminish their apertures, serve 
either to diminish the volume of air taken in at each aspiration, 
or to cause greater effort of the machinery of the aspiration. 

When one of the nostrils of a neonatus becomes stopped by 
dried phlegm, by crusts and scabs on the orifice, or by any fo- 
reign body detained within it, a certain degree of respiratory dis- 
tress is the consequence, because the instinct of the child leads 
it to respire only by the nares, and not by the mouth. Such re- 
spiratory distress is caused, partly by the lessened aeration of the 
blood, and partly by the fatigue or exhaustion consequent upon 
extraordinary exertion of the respiratory muscles. 

Under these circumstances, should the other nostril become 
obstructed, or wholly occluded, it will happen, in many young 



58 CORYZA. 

children, that they shall persist in their efforts to respire only by 
the obstructed nasal passages. In such a case, after making 
two, three or four attempts to respire in vain, the infant starts 
forward, throws its hands wildly abroad, and opening its mouth and 
throat, admits the air in a large stream into its lungs, and then 
immediately resumes its efforts to breathe through the obstructed 
nostrils again. 

The nasal apertures of a young infant are so proportioned, as 
to admit a volume of air, at each aspiration, sufficiently copious 
to aerate the blood in the pulmonary capillaries. If one of the 
nostrils should become totally obstructed, the introduction of air 
into the lungs is, in so far, diminished, or rendered difficult and 
laborious. The child labors for its breath, using the unobstructed 
nostril. 

A child that breathes by only one nostril, imperfectly adapted, 
as it is, for the admission of a volume of air sufficient for its aeration, 
is, as to its aeration, virtually in the same kind of distress as one 
laboring under the early stages of pseudo-membranous laryngitis. 
If, in the progress of the case, the free nostril should also become 
obstructed, the difficulty of breathing would become much more 
manifest; and although the patient might not immediately die, it 
would insufficiently aerate its blood, because it always repeats the 
instinctive effort to respire by the nares, failing in which, it opens 
the mouth and fauces, and, with a sort of respiratory agony, in- 
hales the requisite amount of air, and then renews its attempt to 
breathe through the nares alone. One full aspiration by the 
mouth relieving its present and most pressing want, leaves it again 
to the dominion of its instinct, which is, to respire, as before, 
through the occluded nostrils only. But it is manifest, if this 
representation be correct, that such imperfect and long-intermitted 
respiration will not suffice to aerate the blood, and that ?tn impure 
current, partly oxygenated, partly carboniferous, in the brain, will 
at length lay the foundation of irregular innervations, putting the 
child's life into danger, and which, if continued to a certain ex- 
tent, must bring it to its close. 

It appears to me, that any person, it is indifferent whether he 
be a physician or not, may readily obtain an idea of the kind and 
degree of respiratory distress, that is produced by two or three 
vigorous attem^pts to breathe through a closed nostril, in the fol- 
lowing manner : — 



CORYZA. 59 

Let the person close both nostrils, by pressing the alse with the 
finger and thumb, closing, at the same time, the mouth, and per- 
sist, for some fifteen or twenty seconds, to respire through the 
closed nares ; and then, suddenly opening the mouth, let him 
make the aspiration through the fauces. It is evident, that all 
the sensative cords of the pneumogastric nerve are, in this way, 
at once put in a sort of agony, and it is not to be believed, that 
the sensative cords of this important nerve can be distressed, 
without involving the motor cords in some congenerous trouble. 

Slight affections of the parts innervated by the great vital nerve, 
are sufficient to derange the entire economy, and I doubt not, that 
consecutive attempts of this kind, repeated for two or three days, 
may destroy a full-grown man, and much more readily, a new- 
born infant. 

A few years since, I attended a lady in North Tenth Street, in 
this city, who gave birth to a healthy, though small and delicate, 
child. It did well for some days, and then became affected with 
the slight coryza so common among neonati, on account of which 
it was kept w^arm, and the monthly nurse applied the usual re- 
medy, of greasing the nostrils at bed-time. The mucous secre- 
tion of the coryza gradually collected about the apertures, and 
formed tampons, or plugs, which filled up the entire nostrils, as 
completely as if they had been filled up wdth a vial cork. The 
parents found the child apparently dying, and members of the 
family, from different parts of the city, were assembled to witness 
the decease of their young relative. 

Being notified, by an urgent message, of the dangerous condi- 
tion of the young infant, I hastened to the house, and finding the 
friends solemnized by the approaching event, I, also, was at first 
convinced that the child w^as about to perish. 

It breathed after very long intervals, during which there was 
no apparent attempt to respire; and I noticed, that when it did 
make its aspirations, they were very sudden, rapid and violent, 
after which it relapsed into its non-respiring condition. 

I did not understand the nature of the case, but I remarked that 
it could not be spasmodic nor pseudo-morphous laryngitis, nor, in- 
deed, any laryngeal affection, because, when it did respire, it did 
so with full freedom and perfection, which could not be predicated 
of any affection of the larynx, of the bronchi, or the lungs. 

In the doubt in which I was placed, I took the child on its 



60 CORYZA. 

pillow upon my knee, in order to inspect it more closely ; an in- 
spection which left me no room to doubt that the obstruction was 
in the nares, and upon a closer examination, I found that the 
nares^vere entirely stopped up, as I before remarked. By means 
of the head of a pin I removed the plug from the external nostril, 
but I could not free the deeper parts of the passages. 

Seeing that the child was about to die — and I have, at this mo- 
ment, no doubt that it was, but for the rescue, within half an hour 
of its death — I lifted it in my hands, and, applying my mouth to 
the nostrils, and blowing violently into the openings, I loosened, 
and discharged the plugs into its pharynx, after which it was in a 
few minutes perfectly well, and I had no further trouble with it. 

I saw a little child perish in North Sixth Street, a few years ago, 
from this cause. He had great aspirations at long intervals; the 
nostrils were entirely closed, not by mucus, but by sub-mucous infil- 
tration, bringing the sides into contact, and closing the passage. 
As long as I could sit before him, preventing his tongue from 
touching his soft palate, and keeping his lips from closing, so as 
to admit air into his larynx, the child was perfectly w^ell; but as 
it was impossible, on account of his resistance and struggles', to sit 
before him with a spoon upon his tongue, for many consecutive 
hours, it was necessary to abandon him to his fate, and he perished 
a few hours after I left him, persisting in attempts to breathe 
through an impracticable passage in his nostrils. 

I saw a fine child, nearly two years old, perish, in January, 
1845, from nearly a similar cause. 

Perhaps the reader, perhaps some spectator, might doubt the 
propriety of the explanation of the cause of death in these cases; 
I recommend such cavillers to repeat the attempt of persisting to 
breathe through the nostrils closed by the finger and thumb, after 
w^hich all doubts must vanish from the mind. 

Dr. Underv\^ood, in the Phil. Ed. of 1818, at p. 17, treats of 
coryza maligna, or the morbid snuffles. In his article upon this 
subject, he refers to a paper by Dr. Denman, who, in noticing the 
discharge from the nostrils, appeared to consider the most promi- 
nent symptom of the disease to be, the difficulty of breathing 
through the nose ; a difficulty which, he remarked, was not con- 
stant, or which, being absent, left the child, apparently, in no 
danger. The truth is, that, in these cases of coryza neonatorum, 
although the instinctive tendency is to breathe through the nostrils, 



CORYZA. 61 

in which it resembles adult persons, children will not be found 
always to obey this instinctive law, and without any considerable 
change in the state of the coryza itself, the sufferer will be found, 
at times, to render itself comfortable by breathing, as it can 
breathe, with perfect facility, through its mouth and fauces, and 
then, relapsing into its original tendency, it persists in breathing 
through its nose, until, in some cases, it dies, as I have stated. 

Dr. Denman appeared to have noticed this peculiarity, for he 
observed, that while the child was free from the difficulty, there 
was no apprehension of danger, while at other times, the danger 
w^as clearly so great as to require an attendant to watch over it, 
both in sleeping and waking, in order to open the mouth as 
often as might be required. 

Now, if any practitioner should rely upon relieving the patient by 
simply disparting its lips and gums, he will be likely to fail in his 
attempt, inasmuch as the child makes a valve of the back part of 
the tongue, keeping it against the velum pendulum palati, thus 
completely occluding the orifice. 

Underwood says, that in the course of eight months. Dr. Den- 
man attended eight children afflicted with this disease, six of 
whom died. Mr. John Hunter and Everard Home opened one of 
the bodies, and discovered nothing, except that the Schneiderian 
membrane was of a dark-red color, and its blood-vessels more tur- 
gid than common. 

I can by no means agree with Dr. Underwood that the dis- 
ease is to be safely treated by absorbents and slight purgatives. 
It is a Schneiderian disease, and it may be quite necessary and 
reasonable, in the progress of it, to assist the child to carry off 
large quantities of viscid mucus, often disagreeable in its odor, 
which falls into the pharynx, and, being swallow^ed, cannot 
fail to produce a highly saburral condition of the stomach. But 
I am far from supposing that the disease is gastric in its character. 
I believe a leech applied to each nostril, would be far more effi- 
cacious in mitigating its violence, than any internal treatment 
whatever. As I before remarked, the danger to the child arises 
from one of two causes, of which the first and most common is 
the filling up of the passage with a plug of dried, viscid mucus, 
and the other, a sub-mucous infiltration, causing the sides of the 
cavity to collapse. I would here observe, that the viscosities 
produced within the nostrils, will rarely be found to begin to dry, 



62 CORYZA. 

except at the very orifices; those that are deeper-seated being 
kept moist and fluid by the abundant supply from the sources of 
excretion; whereas, those that are nearer to the orifice, are subject 
at their outer or lower extremity, to become inspissated, and to 
dry into firm scabs. 

Now, for the treatment of this affection. It is an almost inva- 
riable practice, in old women and nurses, and young mothers, to 
grease the child's nose, as it is termed, generally with tallow, or 
some ointment; sometimes with rabbit's fat, or, as Van Helmont 
calls it, " the fat of an hare." In order to prevent the inspissation 
and exsiccation of the outer portion of the mucus, it is well to 
grease the child's nose, but the ointment should be applied to the 
internal, and not on the external surface, where it can do no man- 
ner of good. Olive oil does not answer well for this purpose ; it 
becomes rapidly rancid in the air and in heat, and is vexatiously 
irritating to the parts; it is always better to select an animal oil, 
and, I think, nothing can be found more apposite to the circum- 
stances than the ointment of cucumbers, which is exceedingly 
cooling and emollient, and just sufficiently adhesive for the occa- 
sion. A portion of it, as big as a pea, should be placed on the 
palm of the hand ; a full-sized fitch pencil should take up a suffi- 
cient quantity of this ointment to fill the brush, which should be 
drawn to a point, and thrust into the little child's nostril, after it 
has been carefully cleansed, and delivered of its phlegm. 

The effect of this application would be, to cover the lower part 
of the aperture w^ith a thin glazing of animal oil, upon which the 
viscosities will not rest and dry, but fall outw^ards upon the lip, 
whence they maybe readily wiped aw^ay; whereas, upon the dry 
epithelial surface of the orifice, the viscosities adhere, become in- 
spissated, and convert themselves, as before stated, into hard, dry 
and solid crusts or scabs. 

In advising as to the mode of dressing young children, I have 
for years past recommended the parent not to put any cap upon 
the child's head, whether it be born in the cold, the variable, or the 
warm season. I do not believe that a child dressed with its head 
naked, is, in general, more likely to be attacked with coryza than 
one dressed with the ordinary lace cap, or muslin cap, which is 
still in use among a considerable part of the population. But, in 
all cases of coryza, whether the child have a muslin cap, or whe- 
ther it have a naked head, I have been accustomed, for a long 



BOWEL COMPLAINTS. 63 

time past, to direct that a light flanDel cap, fitting closely to the 
head — not loosely — should be applied, and \Yorn until the coryza 
disappears. In a very considerable number of instances, I have 
found the warmth of a flannel cap, worn upon the head, sufficient 
speedily to cure the malady, and I beg leave to assure the reader 
that, for the most part, I have found little else to be done, beyond 
giving very clear directions as to this method, which deserves ra- 
ther to be called a cure, than a method of treatment. I must beg 
to refer those who would seek for more elaborate prescriptions to 
the formal works; in the meantime, very confidently assuring 
them that few cases of coryza neonati have resisted the treatment 
by the flannel cap. 

There is no child attacked with the disorder, ever so slightly, 
that should be treated with indifference, for wherever the malady 
attains to a certain degree of intensity, the life of the infant is not 
to be considered safe, and there is, at best, a great degree of dis- 
comfort, ^ot for the patient alone, but for the parent also, even in 
the slight cases. 



CHAPTER V. 

BOWEL COMPLAINTS. 

Before proceeding to speak in detail upon the bowel com- 
plaints of children, I propose to offer a few remarks upon the 
alimentary organs, that may assist me more clearly to illustrate the 
meaning and intent of what I shall afterwards say upon the spe- 
cial topics. 

Although the alimentary canal comprises the entire tractus of 
organs extending from the mouth to the extremity of the rectum, 
including the stomach, and the small, as well as the great intes- 
tine; and though, in strictness, we ought not to exclude from the 
physiological consideration of it, certain notions as to the part 
taken in digestion by the liver and the pancreas, it appears to me 
that we may have a very concise idea of it, when viewed as a 



64 BOWEL COMPLAINTS. 

mucous cylinder, which, in the adult, is about forty feet in length, 
by an average breadth of between three and four inches, giving a 
mucous superficies of more than ten. feet. This mucous surface 
is the digestive membrane. 

We ought not, however, in taking so concise a view of the ali- 
mentary canal, to omit a reference to the complicated structures 
that assist, and concur with, the mucous tissue, in the perform- 
ance of the digestive acts. 

For example, the ganglionic system, that mainly supplies these 
organs with nerve-force, is allied to the cerebro-spinal order of 
innervations so extensively, as to subject both systems to the risk 
of disturbance, whenever any malady happens to attack the essen- 
tial digestive tissue, w^hile that essential tissue itself is also liable 
to derangement, both in its physical nature, or crasis, and in its 
functional force, by causes actingoriginally upon the brain or sen- 
sorium or ganglionic nerves. It appears hardly necessary to cite 
the trite examples of a nausea and vomiting induced J^y a blow 
upon the head, or, vice versa, of a pain in the encephalon, pro- 
duced by a bilious or mucous saburra of the primse vise. 

Viewing the nervous mass of any creature as the real, the es- 
sential Ens, it would follow, that a disordered or unhealthy state 
of that nervous mass, whether it be ganglion or nerve, or brain, 
must be in some, and, perhaps, in very numerous instances, the 
prime cause of the malady^ — a malady whose phenomena, or whose 
manifestations, are only to be seen and demonstrated in the tissue 
or organ that is a mere agent and laboratory of the special ner- 
vous mass in question. 

In a general conspectus of the alimentary organs, it is necessary 
to inquire into the nature and state of the lacteal and lymphatic ab- 
sorbents, as well as of the secreting glandules, and mucous crypts 
and follicles, by means of which it is lubricated within; and any 
of which may become seats of disease. 

Again, the moving powers of the intestine are dependent upon 
the peristaltic muscles, which are numerous and powerful, and 
which in health appear to be ever active, never needing repose. 
So great is this activity, that it is probable large portions of the 
muscular apparatus are ever moving while the individual is in 
health; so that, in all such persons, some muscular contractions 
are always going on in some portion of the bowels. When the 
whole tractus is at rest, the individual is not in health. 



THE DIGESTIVE TUBE. 65 

But the mucous tissue, the glands, the muscles, and the nerves 
of the bowels, would remain without any force or action, but for 
the blood that circulates in their sanguiferous tubes. It is worthy 
of observation, that, notwithstanding the vast dimensions of the 
digestive surface — ten superficial feet at the least — the whole tor- 
rent of blood with which it is supplied is appropriated to it alone, 
escaping from the general reservoir of the systemic aorta, by 
the three digestive arteries. 

I call them digestive arteries, since they are clearly consecrated 
to the purpose of digestion, and since the whole stream that is- 
sues from the large apertures of the cceliac, the superior mesente- 
ric and the inferior mesenteric, is propelled upon the digestive 
organ, and upon it only; and since, in its capillary distribution, 
it furnishes not only all the secretions that lend a chemical aid to 
the acts of digestion, but keeps alive the development force of all 
the tissues among which it courses, and to which it imparts its 
oxygen. 

There is further to be made the reflection, that all the arterial 
blood of the three digestive arteries, that is collected by the nas- 
cent radicles of the mesenteric veins, comes to be poured, at last, 
into the portal sinus, whence it undergoes a second distribution 
in the hepatic portal capillaries, where, being collected, it finally 
re-enters the general venous cyst, at the inferior cava, and so to 
the pulmonary heart. 

In addition to all these, we must know that there is an abundant 
cellular tela, and more than that, an enormous expanse of serous 
or peritoneal membrane, which limits the bowel exteriorly, as 
the mucous coat bounds it internally. 

Having made this inspection of the very complex apparatus 
that is provided in aid of the digestive membrane, one may clearly 
perceive that the disorders of the alimentary system are various, 
and that they may be affections either of the mucous membrane, 
its crypts and glandules ; its nerves, its muscles, or its sanguife- 
rous and absorbent tubes; or its cellular, or its serous apparatus. 

It is easy to imagine that any causes that should modify the 
state of the circulation in the intestinal capillaries of the digest- 
ive arteries, might greatly affect the condition of the hepatic 
portal system, and vice versa. For example, a solidified liver 
rendering the return of the portal blood to the cava very difficult, 
or in some degree impossible, might determine a state of chronic 
5 



66 BOWEL COMPLAINTS. 

engorgement of the distal capillaries of the mesentery, or even 
lead to fatal excretion or effusion of blood into the intestinal 
canal. 

In like manner, the disorders of the bowels might well be looked 
to as causes of the suspension of the hepatic functions, or, at 
least, of great modifications- of their rate ; as, for example, in 
Asiatic cholera, in which it is a rare event to observe even the 
smallest portion of bile in the wasteful evacuations by vomiting 
and stool — presenting a case not very dissimilar to that of cho- 
lera infantum, in which the most exhausting colliquation of thfe 
bowels seems to preclude any biliary secretion, on account, per- 
haps, of this, viz., that all the excretable portions of the digest- 
ive circulation have been already thrown off in the alimentary 
tube, leaving only what the writers of the renaissance would pro- 
bably denominate a dry and adust blood, to flow in the hepatic 
portal capillaries. 

It is well known, that, in some of the mucous and muco-serous 
bowel complaints, the appearance of bile is to be hailed as one 
of the signal precursors of a cure. 

But, as I have no intention to make a dissertation upon patho- 
geny in this little volume, I shall now proceed to some observa- 
ations of a less general nature, upon certain of the alimentary dis- 
orders of young children, and first: — 

In the human being, as well as in all other mammalia, the 
offspring comes into the world dependent for its early supply of 
nutriment upon the secretion of the mammary gland of the parent ; 
and it is a law of nature that an abundant supply of nutriment 
shall not be prepared until some hours after the birth of the new 
creature. 

Physicians ought to reflect upon this law as founded in that sure 
prevision which has co-ordinated all things of this world for the 
perfect production of a necessary end. 

In the human female, the expulsion of the fruit of the womb 
allows the gestative organ to return towards its non-gravid con- 
dition; and from the act of expelling the child, which has reduced 
it from the gravid state, to the condition of the uterus some ten or 
fifteen hours after delivery, it is so greatly altered as to its power 
of receiving and discharging the blood sent into it by its arteries, 
that one will have no surprise to find new and powerful sanguine 
determinations the result of the sudden cessation of long accus- 



EARLY FEEDING. 67 

tomed uterine affluxions. The new determinations, ordinarily and 
normally, take place towards the mammary glands, and it is not, 
as a general rule, until towards the third day, or seventy-two hours 
after the labor, that the mammary gland begins to yield its first 
and richest abundance of nutritious food. 

A child just born is therefore clearly not designed to be put at 
once to a breast filled with milk, because the wise prevision of 
nature would undoubtedly have furnished it with an abundant 
element at the moment of its birth, had such provision been really 
necessary for it. Now, if these observations are founded upon the 
truth of nature, it appears to me that we have a fair inference 
from such a truth, that the young child should not be filled with 
food immediately after it is born, and yet, of the thousands of 
children that are yearly born in the United States, the exceptions 
are few and far between, of those whose stomachs are not crammed 
with some pernicious mixture of molasses, or sugar, or honey, or 
grease, or gruel, within little more than half an hour after they 
come into the world. 

Physicians know that a child is made for the milk, and the 
milk is made for the child, and that the milk is not prepared for 
it until the third day. 

Now although the American new-born baby does not die from 
taking molasses and water, he is, in nine cases out of ten, at- 
tacked with dyspepsia, gastric acid, and phlegm, from which he 
suffers immensely during the month, and perhaps during his 
whole future life, and from which he might escape were the clear 
provisions of nature's law fully understood and implicitly obeyed. 

God is wiser than man ; and as the laws of nature are but the 
dicta of his will and of his benevolence, we can never err if we 
clearly hear, understand, and fulfill them. 

Anew-born child undoubtedly comes into existence with many 
instinctive desires and appetites, the most powerful of which is 
that for the ingestion of food. I have on many occasions applied 
a new-born child to the breast of the parent, within a quarter of 
an hour after its birth, and have observed it with the greatest 
avidity, perform the act of sucking as perfectly as if it had been 
accustomed to it for months. 

There are few women in whom the breast fails to furnish a few 
drops of whey-like fluid, which, together with its own saliva, 
swallowed by the child, serves to satisfy its instinctive cravings ; 



68 EARLY FEEDING. 

and, if the application to the breast be repeated from time to time, 
as often for example as once in three hours, such a proceeding 
serves not only to appease the infant itself, but also in a remark- 
able degree to promote the development of the granules of the 
mammary gland, by stimulating the nipple. There is doubtless 
a moral influence produced by the application of the child to the 
breast, which reacts in a powerful manner upon the physical forces 
which are supposed to determine the secretion of milk; and the 
woman's milk may be generally expected to come more easily, 
certainly and safely, if the nurse applies the child early to the 
breast, than if, under some imaginary conception of her duty to 
it or to herself, she defers it to the second or third day. It is cer- 
tainly not a rare occurrence, that a woman who loses the child in 
the birth, fails wholly to furnish any milk — and it is equally 
obvious that the emotions of the parent's mind relative to her 
offspring, exert a powerful influence to promote the more abun- 
dant secretions of the breast. 

I know not, and I believe it is not known, whether any pecu- 
liar function or power is connected with the ingestion of the early 
milk of the mother, a fluid known to be characterized by the 
presence of a large quantity of colostrum, but it is understood 
among the agricultural class, that the ingestion of milk of the cow, 
which agrees well with the new fallen calf, is unwholesome to 
human beings, being likely to produce disorders of the stomach, 
accompanied with purgings. 

M. Rainard, in the Traite Complet de la Parturition des Prin- 
cipales Femelles Domestiques, torn. ii. p. 151, after speaking of 
the milk fever that occurs also in the cow, says that the milk fever 
in this animal is far less decided than in the human female, and 
that the symptoms of the malady are most apparent in those cows 
that furnish the greatest abundance of milk. These observations 
of M. Rainard show that a similar effort of the constitution is 
required in the domestic quadruped, and probably in all the 
mammiferous quadrupeds, to that which is required in the human 
female, audit appears to me to be a direct accusation against Pro- 
vidence to suppose that the tender young, the object of so much 
care, should be left unprovided with an element deemed by the 
vulgar so essential for it at the moment of birth. It appears to 
me that it teaches us, as to the management of the early infant, a 
lesson whose doctrines are not to be gainsaid, and that those 



MILK. 



69 



physicians are absolutely right, who forbid the monthly nurses to 
give to the new-born child pernicious mixtures of molasses, and 
sugar, and other substances, which cannot fail to ferment, giving 
rise to the evolution of great quantities of acids and of gas that 
torment the little sufferer, and require to be afterwards cured by 
the administration of drugs scarcely less pernicious than the food 
itself. 

The rule, therefore, should be not to feed the new-born child, 
but to w^ait until the food provided by nature as a true generical 
aliment shall be produced. 

It is very true that if the mother be lost, or if she give no milk 
in due time, a succedaneum must be provided, which should be 
as nearly like the mother's milk as possible. A newly-born mam- 
miferous animal requires for its nourishment proper quantities 
of cream, which is oil; of casein, which is cheese ; of albumen, 
which is white of eggs; and of water. These are generical for it; 
and, if the mother or the dam cannot supply them, as near an 
approach as possible to the qualities should be provided for it by 
taking the food of some other mammiferous quadruped. 

To show the variety and differences of milk, it is only neces- 
sary to appeal to the chemists. 



In cowls' milk Simon found : 




Of Water .... 


857-0 


" Butter .... 


40-0 


" Casein .... 


72-0 


** Sugar and extractive matter 


28-0 


" Fixed salts 


6-2 


In asses' milk he found : 




Water . . . . 


907-0 


Butter wdth metallic acid . 


12-10 


Casein .... 


16-74 


Sugar with extractive matter and salts 


62-0 


In goats' milk there has been found: 




Water . . . 


868-0 


Butter .... 


33-2 


Casein .... 


40.2 


Sugar .... 


52-8 


Salts 


5-8 



7a 



MILK. 



In the milk of the ewe : 




Water .... 


632-0 


Butter . 


58-0 


Casein .... 


15-30 


Sugar . . 


42-0 


Cream . . . 


115-0 


In the milk of the bitch, the analysis gave : 




Water .... 


657-4 


Butter .... 


162-0 


Casein .... 


174-0 


Extractive matter and Sugar 


29.0 


Fixed salts . . 


15.0 



Milk is the nutriment of young animals. There may be found 
for it a succedaneum, yet it will be only a succedaneum. A 
proof of the highly nutritious nature of this substance may be 
found in this, that a young elephant which at birth may weigh 
200 or 250 pounds ; in a few months will come to weigh 650 
or 700 pounds, living solely upon the milk of its dam. It is said 
that the young of a Balsena Mysticetus is more than 20 feet in 
length at birth; and attains a vast size while depending solely on 
the milk of the dam. 

Goat's milk, cow's milk, or asses' milk, is a better substitute 
for mothers-milk than gruel, arrow-root, or any other artificial 
aliment. Simon gives at page 51 of volume II. of his work, five 
of his own analyses of the milk of the human female. I will take 
one of them for all. Let it be the third, which makes it consist of: 

W^ater .... 898-0 

Butter . . . . 28-8 

Casein .... 32-0 

Sugar of milk and extractive matter . 36*0 

If this be compared with the analysis of cows' milk, it will be 
found that the water in the cow's milk was 857*0, and the butter 
40-0, w^hile the casein was 72.0, and the sugar of milk and ex- 
tractive matter 28-0; nearly double the quantity of casein, and a 
greater quantity of sugar, and a smaller quantity of water. 

The comparison of the cow's milk with the milk of the human 
female, showing the greater quantity of casein, may serve to ex- 
plain the fact, that, in the substitution of cows' milk for the mo- 



MILK. DIET. 71 

ther's milk, the child gets a greater quantity of casein, which may 
account for the frequent occurrence of indigestion after the use of 
the substitute. It is doubtless the casein which most commonly 
disagrees with the young child, and not the creamy or oily portion ; 
this is shown by the examination of the napkins of the infant, on 
which, under circumstances of serious indigestion, are always found 
masses of casein or cheese. Sometimes these portions of undi- 
gested cheese are hard, white, resembling new cheese that is bought 
in the market — evidently a casein insoluble in the stomach. 

There must be some proportion, or some relation between the 
proportion of cheese in cows' milk, asses' milk, &c., and the 
digestive force of the young creature of each such animal re- 
spectively; a relation accurately and justly adapted to its wants 
and its powers ; the medical man, therefore, who prescribes a diet, 
a succedaneum, should endeavor to bring the relations of the con- 
stituent elements, as nearly as possible, into accordance with the 
generical nature and wants of his little patient. By adding water 
and cream to cows' milk, the proportion of casein may be reduced, 
and the mixture brought into a close approximation to the nature 
and quality of the milk of the human female. I have known some 
physicians to prescribe a tablespoonful of cream, with half a cup- 
ful of water and a teaspoonful of sugar, as the sole support of a 
young child deprived of its mother's milk ; it appears to me that 
this is a serious error, since it is an error to omit in the compo- 
sition, some proportion of casein, which probably contains more 
protein than the other parts of the milk ; the more particularly as 
in taking off the cream, there must be left behind all the albumen. 

In confecting the artificial diet of the young child, in addition 
to the caseous and butyraceous elements, experience shows that 
it is safe to make use of some one of the various kinds of fecula, 
such as the arrow-root, tapioca, or sago, and also some of the 
farinaceous articles, which in many children, are found to answer 
perfectly well, and to effect rapid development, without producing 
sourness and indigestion, provided there be always a proper pro- 
portion of the materials which nature provides for all the mammals. 

A young child, whose diet consists principally of milk, might, 
under such circumstances, be fed two or three times a day, with 
gruel, prepared from oat-meal ; or, gruel prepared from rice, with 
many children is found to answer perfectly well. Barley water, 
well prepared and mixed with milk, forms a combination of vege- 



72 MEDICINE. MECONIUM. 

table and animal aliment, which, for many children, is highly- 
salutary. 

It is customary in the use of these articles, to change them from 
time to time, with a view to diminish or increase the amount of 
peristaltic and intestinal action. A diet of milk, of oatmeal, of 
barley flour, is more likely to prove aperient to the child, than one 
composed of wheaten flour, of rice, or of crackers; the rule so 
often cited, however, as from the lips of our venerated citizen, 
Dr. Samuel Powell Griffitts, is one that ought not be lost sight of, 
that is, "It is well to let well enough alone;" if a child, there- 
fore, is doing perfectly well upon a system of alimentation, one 
ought not to incur useless hazard in changing that which is well, 
in the hope of finding something that may be better. 

As to medicine for the new-born child, it must be admitted, that 
to give medicine to a child, because it is young, or because it is 
new-born, is utterly preposterous, yet, so far as my experience goes, 
there are great multitudes of children who are compelled to take 
a dose of nauseous physic within forty-eight hours after their birth ; 
which is given under the impression, that it is necessary in order 
to discharge the meconium, or under some notion that it must have 
physic because it is new-born. 

The meconium is a dark-colored — almost black — greenish and 
viscous substance with which the colon and rectum of a new-born 
child is ordinarily found to be filled ; a considerable quantity may 
be observed in the colon of a child under five months in the womb. 
The quantity in some new-born infants is very great, indeed ; so 
considerable as greatly to distend the whole of the large intestine: 
it is often discharged into the womb in labors, and there are few 
cases of breech or footling births, in w^hich it is not found to es- 
cape before the completion of the act of parturition. I am under 
the impression that, in most children born, dejections of this me- 
conium will be found to take place within twelve hours after the 
infant has come into the world, and it is considered rather out of 
the rule, for the child not to have one or two copious evacuations 
in the course of the first day. As this meconium is found in the 
large, and not in the small intestines, it is easy to perceive that a 
very considerable action of the bowel might be capable of dis- 
charging the whole of it in the course of two or three operations, 
whereas a torpid or comparatively insensible alimentary tube 



MEDICINE. 73 

would discharge it gradaiim, and fail to get rid of it in the course 
of even two or three days. 

As soon as the black matter passes off, its place is taken by a yel- 
low substance which descends from the duodenum and jejunum, 
passing through the ileum into the colon, and giving rise to the 
bright yellow-tinted dejections of the new-born child. When 
the meconium comes off freely and entirely, as is known to be 
the case w^hen it is chased away by the bile-tinted product of the 
small intestine, it is clearly unnecessary and inexpedient to ad- 
minister medicine for the production of an effect already produced ; 
and in fact it is very desirable, in the young child, as it is in all 
persons, to withhold the exhibition of drugs and medicines except 
upon a clearly perceived reason, and marked necessity for their 
employment. 

It appears to me to be an outrage to give a child a dose of cas- 
tor oil, or rhubarb, or magnesia, when it is not really required ; 
for such articles cannot be taken into the stomach without excit- 
ing the beginning of trains of actions, whose end no man can 
foretell ; and, though it is true that a dose of castor oil will in the 
general operate only some three or four times, it is also true, that 
it sometimes produces very distressing gripings, which are evi- 
dences of violent disturbance in the innervations of such import- 
ant textures : but a new-born child ought not to be exposed un- 
necessarily, to the risk of violently exciting the nervous mass of 
its alimentary organs. Those physicians, therefore, who dispense 
with the use of medicines, until they are clearly called for by 
the urgency of the distress, or some symptoms of disease, are in 
my opinion the most commendable. 

On the third day, as has been before mentioned, the breast 
glands of the mother are filled, and the production of milk is so 
great, that the young child is frequently found incapable of ab- 
sorbing the whole of it. If the breast be what is called a ofood 
breast, or one that is easily drawn, one in which the galacto- 
phorous tubes are easily produced by the sucking of the child, its 
stomach becomes rapidly filled with a mass of milk which distends 
it to its utmost compass: many children, under these circum- 
stances, have the happy faculty of rejecting the excess. Such 
children, after having been applied to the breast, are found to pour 
out over the under lip, without vomiting, but by a kind of eruc- 



74 DIARRHOEA FROM INDIGESTION. 

tative force, a sufficient quantity to leave the stomach comfortable, 
not uncomfortable from a state of inordinate distension. 

But there are a great many children who have not this ready 
faculty of relieving the stomach of their excessive ingestions. Now 
in these little creatures, the excess passes off through the pylorus 
before the changing action of the stomach can be exerted upon 
the mass; the duodenum, the jejunum, the ileum become filled, 
not with chyme, but with milk, which, having been more or less 
perfectly coagulated by the rennet-power of the stomach and 
duodenum, passes off into the colon as whey, or as granules, or 
as flocci of casein, giving rise to numerous discharges upon the 
napkins, which are mistaken for diarrhoea. The physician being 
summoned, and being told that the child has had twenty napkins 
per day, is more apt than not to imagine that so great a diarrhoea 
is the result of disordered muco-secretions or muscular action 
of the absorbing intestine, and the child, if it gets a dose of calo- 
mel, or rhubarb, or castor oil, or some other aperient, is wrong- 
fully prescribed for, since it requires a hygienical, and not in the 
least degree a therapeutical treatment. Such a child, if left in the 
hands of nature, will, in a short time, come to be able to make 
use of the whole amount of its ingesta; or, the breast itself will 
change the rate of the producing power, so as to give the child 
all it wants and no more, upon which the supposed diarrhoea will 
disappear. 

I have been called to see children afflicted with such a supposed 
diarrhoeato the amount of twenty napkins per diem, many of which, 
being reserved for my inspection, have exhibited no signs of 
bilious or mucous disorder. The absence of such physical signs, 
and the presence of all other signs of good health and compla- 
cency in the infant, has invariably disarmed me of my purpose 
to treat it with a strong hand ; nor have I met with any embar- 
rassment from the difficulty of persuading the anxious parent that 
the malady was more seeming than real, and that therapeutical 
remedies, by means of which such discharges could be arrested, 
would prove not only unnecessary, but dangerous. For I have 
shown her that the reasonable mode of treatment consisted in 
diminishing the amount of ingesta, by putting away the child from 
the nipple whenever she should deem it had taken a sufficient 
quantity, and in never allowing it to gorge itself ad gulam. 

It is not difficult to make the diagnosis in this case, because, 



GREEN DEJECTIONS. 75 

by a little careful inquiry into the state of the breast; as to the 
draughts that come into it; as to the magnitude and fullness of the 
breast before it is given to the child, and as to its flaccidity after 
the child has taken it ; as to the number of times per diem that 
the infant is admitted ; and, more than all, by a careful inspection 
of the product of the dejections — to determine the point of neces- 
sity, whether as for prescription, or as for abstaining from it. 

But children are often affected with diarrhoea and gripings. 
Sometimes the acid which occurs in the early stages of the pheno- 
mena presented in the gastric and intestinal series of digestions, 
is excessive in quantity: the presence of such substances in those 
delicate passages, is not unlikely to produce purgings by irritating 
and titillating the impressible extremities of the digestive nerves; 
whereupon they provoke abundant secretions of mucus, and excite 
the whole series of arteries and capillaries that carry the blood of 
the intestinal canal, the vena portse and the liver; so that the pre- 
sence of excessive quantities of acid may naturally be expected 
to derange the action, not of the muscular coat of the intestines 
only, but of its mucous coat, as well as the liver, whose condition 
is often determined by the state of the portal circulation. 

I do not apprehend that the liver ever produces green bile; but 
it may produce an excessive quantity of yellow bile, whose nature 
may be vitiated by hepatic irritation, and this yellow bile, poured 
out through the choledoch into the intestinal tube, strikes a green 
color on coming into contact with the colorless acids of the sto- 
mach and duodenum ; so that all the alvine discharges that take 
place from the young infant are colored green — green as verjuice, 
green as a leek — of various shades of green. Whenever such 
color of the stools is perceived, it is to be taken for proved that 
the child has acidity of its primse vise: it has not green bile, but 
it has yellow bile which strikes a green color on being mixed w^ith 
acid, precisely the same tint being produced out of the body, by 
mixing the pure yellow bile with acid in a wineglass. 

It must be evident that the presence of an excessive quantity 
of acid in the primae vise, cannot fail to irritate these tender mem- 
branes; and, as the production in some instances goes on not- 
withstanding very frequent and copious dejections, it is proper to 
provide some means for the relief of the suffering infant. 

A child that suffers griping and spasmodic pains of the belly, 
is restless, expressing its discomfort by frequent and sometimes 



76 GREEN DEJECTIONS. 

protracted loud cries — by drawing up, and suddenly extending 
its limbs, and by a desire to relieve itself at the breast, upon 
which its demands appear to be as it were insatiable. In some 
instances a regular and steady operation of the function of the 
peristaltic muscles, sufficing to carry off from the primse vise the 
irritating matters, will soon relieve the child of the spasm, but, 
when the passages take place irregularly and imperfectly, it is 
proper to give one or more doses of aperient medicine. It is dif- 
ficult, I should think, to find an aperient more suitable to effect 
this design than the castor oil, of which the dose is a teaspoonful 
or half a teaspoonful as the occasion may seem to require. 

Some of the milder forms of disturbance, arising from the pre- 
sence of acid in the primse vise, may be readily relieved by ex- 
hibiting several times in the course of the day doses consisting 
of a teaspoonful of lime water, mixed with as much milk or breast 
milk; — or by doses consisting of from one to three grains of the 
bicarbonate of potassa dissolved in a small quantity of spearmint 
w^ater sweetened with sugar, which may serve to neutralize the 
acids of the stomach or duodenum. 

If the action of the liver be not unhealthy, it will be found that 
the stools become tinted with yellow bile as soon as the cause of 
their greenness, namely the acid, is removed. Doubtless some 
of these cases of troubled primse vise may depend upon too great 
a susceptibility of the mucous membrane, and its muciparous 
apparatus : under such circumstances it is not imprudent to com- 
bine with the use of alkaline remedies and gentle aperients small 
portions of tincture of opium, of which the dose for a child within 
the month, ought not to exceed a drop, while the dose for a child 
under ten days old, is commonly to be deemed sufficiently large 
if half a drop be given at each time. 

Many persons are fond of ordering, under these circumstances, 
a dose of calomel, to change, as they say, the action of the liver; 
and there is no doubt that the impression of mercurial doses upon 
the sensitive surface of the digestive organs, may serve on many 
occasions to alter the modality of the life-actions in those import- 
ant viscera ; but, inasmuch as the impression of mercury is occa- 
sionally very violent, and uncontrollable in acting on the consti- 
tution of the young child, it seems to me desirable to avoid its 
use except when the indication for its administration is clearly 
discovered. In the instance of an irritation of the primse vise of 



GREEN DEJECTIONS. 77 

a young child, attended with purging, crying, and uneasiness, and 
marked by frequent green dejections, we ought not always to 
accuse the liver of being in fault, since these circumstances are 
more frequently attributable to a faulty action of the stomach and 
duodenum, than to a status of the hepatic porta, or the hepatic 
artery, as agents for carrying on either the circulatory or secretory 
offices of the liver. More especially is the liver to remain free 
from any accusation of disorder, when the healthy tint of the child's 
skin, and the absence of a yellow tinge of its adnata, leave no 
valid reason to suppose the functions of the liver to be interrupted. 
Such cases, after the administration of one or two doses of some 
simple aperient, for example, may be more safely managed by 
means of the antacids before referred to, and by the proper ab- 
sorbents, such as prepared chalk, or the prepared crab's eyes, or 
the prepared oyster shells. 

In general, I apprehend, in the administration of the cretaceous 
articles, we fail in consequence of administering them in too 
small doses. Prepared chalk, when well washed and levigated, 
seems to me to be quite innocuous in the young child's stomach ; 
and it is safely given in doses of three or five grains if well sus- 
pended in mucilage of gum Arabic, sweetened with sugar; to 
w^hich also a small portion of cinnamon water, or spearmint, or 
peppermint, or any aromatic distilled water, may be added to 
make it agreeable to the palate and the internal organs. 

In giving prepared chalk, I deem it a good method to direct 
the nurse to administer a proper dose, to be repeated soon after 
the recurrence of each green or sour dejection. Where a small 
portion of laudanum appears to be a desirable addition to the 
medicine, the proper quantity of that article should be added to 
each dose, and not to the whole compound ; in this way it may be 
continued or suspended at the discretion of the prescribing phy- 
sician or his agent. 

A very suitable medicine for the young child affected with acid 
passages, in which there may seem an indication to carry off the 
whole contents of the alimentary tractus, is found in the pure cal- 
cined magnesia, five or six grains of which, suspended in milk, 
or in spearmint water, may be given from time to time until its 
aperient operation is perfectly effected. 

But as a young child is generally by nature a glutton, and hav- 
ing only its instinctive desire for food as its guide, it often renders 



78 SUCKLING. 

itself sick by excessive ingestion. The medical attendant ought to 
make inquiry as to the frequency of its presentation to the breast, 
and the power of the nurse to supply copious or scanty streams 
of nourishment for it. Mothers frequently ask the question as to 
how often the child shall be applied to the breast: if the w^oman 
supply milk freely, to feed the child once in two hours is mani- 
festly to do so too often; we not unfrequently find, however, that 
young mothers have the habit of giving nourishment to the child 
every time that it appears discontented, so that the organ of di- 
gestion has no time to rest; in such cases there is never a moment 
in which it can be quite contracted or emptied. 

I do not know precisely how long a time is required for the 
digestion of a gastro-morphous coagulum of milk, equal in size to 
the greatest capacity of the stomach, but it is clear to me, that 
the stomach should occasionally be allowed to contract itself com- 
pletely, for I cannot see how it can well maintain itself in perfect 
health, if it be not now and then allowed to contract, and condense 
all its tissues. As well might we suppose a urinary bladder to 
maintain its healthful condition, while prevented for a series of 
days or weeks from becoming completely emptied and condensed. 

The stomach does certainly require intervals of repose from the 
sort of digestive crisis which takes place after each meal ; it is 
probable that a healthy child, supplied by a breast at an ordinary 
rate, will be able to discharge the whole of the ingesta into its 
duodenum in the course of three hours. If this opinion be not 
incorrect, it would seem proper that the child should be allowed 
to go to the breast as often as once in three hours, and even in 
this case, if the supply be very copious, the mother should be 
advised to put the infant aside, whenever in her judgment, it has 
taken a sufficient quantity. A little hygienical precaution in 
these cases, may serve to avert the attack of indigestion, which 
often proves to be the first symptom of a long series of maladive 
aflfections. 



JAUNDICE. 79 



CHAPTER VI. 

ON INFANTILE JAUNDICE. 

It is very common to find a new-born child affected with 
yellowness of the skin and adnata ; the urine becomes yellow also 
in these cases; so much so as to leave its stain upon the napkins. 
These circumstances are sufficient, I think, to show that there is 
regurgitation of the bile, and this regurgitation must take place 
somewhere in the liver ; for it will not be contended, I suppose, 
that the coloring matter of the bile is developed as such in the 
blood; it is the product of the secretory power, and, as the secre- 
tion can only take place in the biliary organ, to see a child's skin 
stained yellow, while its adnata and its urinary secretion also ex- 
hibit the same tint, is proof positive of hepatic obstruction. 

The obstruction may doubtless, in some instances, depend upon 
certain pathological conditions of the ductus communis choledo- 
chus, conditions perhaps dependent upon viscosity of the mucus or 
bile at the orifice of the tube, or in the tractus of the tube, upon 
some engorgement of the submucous tissue of the tube, or of the 
submucous tissue of the intestine in the neighborhood of the tube, 
preventing the efflux of bile that has been properly secreted in 
the liver. I believe that there is a common communication be- 
tween the tubes of the hepatic portee and the hepatic veins, the 
hepatic artery and the porii biliarii, rendering it possible for he- 
morrhage to take place from the liver, from the branches of the 
artery, or of the veins, through the pori biliarii, and therefore ren- 
dering equally possible a regurgitation of bile with its coloring 
matter into the blood, which stains the white and transparent 
tissues with its peculiar hue. 

I have not been accustomed to give myself much concern about 
the infantile jaundice, in a child, of whom the dejections have 
exhibited no morbid characteristics ; for I have considered that the 
bright marigold hue or gamboge tint of the dejections, was to be 
taken as undeniable evidence, not only that the liver was carry- 
ing on its secretory action, but that the common choledoch was 



80 JAUNDICE. 

pervious, shedding the bile into the duodenum, as in health, and 
leaving no doubt on the mind that the constant flow of bile into 
the duodenum, must at length suffice to relieve the liver of the 
condition which had led to the regurgitation into the blood. I 
have, therefore, allowed many a case of infantile jaundice to pass 
-without administering for it a single dose of physic ; for, I have 
not know^n w^hat to give: under these circumstances, the exhi- 
bition of small doses of calomel I have thought more likely to 
disturb its digestive powders, than to relieve it from the obstruc- 
tion, which promises in this way to be transitory. 

But, where I have found that, together with the yellow stain of 
the skin from regurgitation, there has been reason to suspect that 
the flow of bile into the duodenum was obstructed, I have endea- 
vored to perfect the diagnosis by all the means in my power. As 
a general rule, a child who does not secrete and discharge healthy 
bile into the duodenum, will constantly lose in w^eight, for the pre- 
sence of the bile in the intestine is a condition necessary to the 
perfect performance of the digestive functions of the upper portion 
of the tube. The absence of bile in the alvine dejections is con- 
clusive evidence of a suspension of the excretion. 

Dr. Thomas Schwann has shown, by his series of experiments 
performed at Louvain, that animals become emaciated when the 
choledoch is tied up, and a fistulous orifice formed, through which 
the bile is discharged upon the surface of the body, instead of 
into the alimentary tube ; and that the animal loses its life, if 
prevented from licking from the external wound, the outflowing 
product of the hepatic secretion. The presence, also, in the blood 
of a regurgitated bile, cannot fail to vitiate the physiological 
powers and functions of that important fluid, acting upon the nerv- 
ous system to interrupt, and injuriously modify its innervative 
forces; hence, a true jaundice, wdth obstruction to the flow of the 
bile into the bowels, is a matter worthy of the attention of the 
physician, even in the case of the youngest infant. 

In such a case, the child ought to be undressed and laid upon 
its back upon the bed, or held upon a pillow upon the lap of the 
nurse, in order that the physician may have a fair opportunity to 
explore the right hypochondriac and the epigastric regions. Many 
children are thus found to be what the nurses call liver-grown, that 
is to say, the liver is swollen and enlarged, so that its anterior edge 
projects far below the cartilaginous margin of the thorax, be- 



JAUNDICE. 81 

coming perceptible when the fingers are pressed along that edge. 
If the child have been born in health, and be only a few weeks 
old, and, if upon making pressure upon various parts of the en- 
larged organ, it becomes evident that the patient feels no pain, 
and if, indeed, the whole series of phenomena present themselves 
without the attributes of an accompanying fever, there will be 
reason to regard the swollen state of the liver as a mere engorge- 
ment, and not as an inflammation of the organ. 

I am unacquainted with the precise principles of the pathology 
of this condition ; I am hardly willing to attribute it to faults of 
a simple excessive sanguine determination to the capillary termini 
of the hepatic artery; and it is equally difficult to assign as a cause 
for it, any affection of the hepatic veins ; it is probably, therefore, 
a fault essentially resident in the capillary terminations of the 
hepatic portse. It only remains to suppose that the sanguine 
engorgement is to be referred to a fault in the condition of the 
digestive circulations which issue from the aorta, — that is, by the 
coelic and the two mesenteries, — hence, the farther inference that 
the trouble in the hepatic functions is pathologically connected 
with some faulty action of the capillary ramifications of the three 
digestive arteries above named, or of the venous capillaries of their 
second expansions in the substance of the biliary organ. 

This leads us again, in considering the therapeutical wants of 
such a case, to inquire how far these wants can be answered and 
satisfied by such modifications as it is in our power to provide, 
in the arterial capillaries of this mesenteric system, by acting 
upon the digestive tube. 

In speaking of modifications of the circulation in the hepatic 
portal capillaries, as well as in the capillaries of the digest- 
ive arteries ramifying beyond the mesentery and , mesocolon, it 
should also be understood that the status, the modality of the life- 
action in these capillary vessels, is dependent on the perfectness 
of the nerve power conveyed into them by the distal extremities 
of their nerves of supply. It is certainly out of the power of 
medical men — notwithstanding they may admit that these health 
modifications are essentially nervous modifications — to have any 
other cognitions of them, than those derived from alteration in 
the volume, sensibility, or function of the part that may be in 
question. 

To speak of a phlogosis or an engorgement of an obstructed 
6 



82 JAUNDICE. 

liver, is, in essence, to speak of a lost power in the nerves of that 
organ to maintain its dependencies in a state of health. The 
necroscopic scalpel is incapable of detecting changes in the ner- 
vous fibrillae in question, although it readily detects slight modifi- 
cations in the state of the capillary vessels, acini and absorbent 
and excretory ducts of the part. Therefore, when I speak of 
modifications in the circulation of the liver, as causes of these 
maladies of young children, I mean to be understood as speaking 
of the modifications of the nerve power of the liver. 

In a case of evident infarction or obstruction of the liver in the 
young child — a case marked by sour purgings; by stools not 
colored with bile; by a yellow color of the skin and a yellow hue 
of the adnata ; by a sort of hectic frequency and quickness of the 
pulse; by a hardness or tumour to be detected by palpation of the 
epigastrium, or of the right hypochondrium ; by yellow bile-tinted 
urine, or other undeniable evidence of hepatic derangement — the 
aid of the therapeutist is clearly necessary. Baths, frictions, dia- 
phoretics, regulation 'of the quantity of the food, careful choice of 
it as to its quality — to which end the nurse may be charged ; 
— emetics, purgatives, topical depletion by means of leeches; 
what are called alterative medicines, and last not least, expec- 
tancy — comprise nearly all the resources of the physician against 
the case. 

A bath in such case should scarcely be of a temperature lower 
than 96° F. Frictions, shampooing of the abdomen — using for 
the purpose of friction, olive oil, tempered perhaps by the addition 
of a small quantity of tincture of opium or some fine aromatic 
oil, such as oil of rhodium, oil of juniper, oil of cloves, or rec- 
tified oil of amber; or camphor or ammonia ; these furnish legiti- 
mate grounds of expectation to favor the progress of the embar- 
rassed circulations, and assist in setting free the course of the nerve 
streams of the disordered part. 

As a diaphoretic, perhaps for the young child, nothing could 
be more suitable than the administration of wine or syrup of 
ipecacuanha, with a very small quantity of the sweet spirits of 
nitre. I hold it to be imprudent to administer to the child within 
the month, doses of Dover's powder, since the least carelessness 
on the part of the apothecary, might readily suffice dangerously to 
narcotize so young a subject; all the therapeutical force apper- 
tainijig to Dover's powder can be obtained by the exhibition of 



JAUNDICE. 83 

half a drop or a drop of laudanum, in combination with five or 
six drops of the wine or syrup of ipecacuanha — a far superior 
method of prescribing. 

With a view to promote the diaphoretic operation of such doses 
as I have now mentioned, it should be deemed indispensable to 
render the child comfortable as to its dress; its napkins should be 
carefully changed whenever they become soiled or wet, and the 
dress also should not be allowed to chill the infant, a circum- 
stance very likely to occur if it be left unchanged after being 
thoroughly wet up to the back. 

In the United States our females are in the habit — even in the 
coldest w^eather, even in the variable seasons of autumn and spring 
— of dressing the child in the most improvident manner, exposing 
the whole of the arm, and half of the thorax before and behind in 
what are called low-necked dresses. An infant, so sick as to 
require to be put into the hands of the physician, ought to be put 
wholly under his control or guidance ; and yet physicians often 
find it an extremely difficult matter to bring about the changes in 
the dress of the infant w^hich they deem if not indispensable, at 
least most desirable. In regard to the class of affections now 
under consideration, I believe there will be found few dissenting 
voices to the proposition, that there is a great natural alliance 
and dependence, between the functional states of the skin, and the 
biliary organs, and that w^hatever here tends to check the exer- 
cise of the power of the cutaneous exhalents — to do which nothing 
is more powerful than cold and damp — ought to be most carefully 
avoided. The young child, then, in this view of the case, ought 
to be dressed with long sleeves, and with frocks high in the neck. 

In children laboring under our disorder, great attention ought 
to be paid to the kind of food. These disorders are not likely to 
occur in children born healthy and nursed at the breast of a 
healthy woman yielding abundant supplies of milk; they are far 
more likely to be met with in those unfortunate beings, who, de- 
prived of their mothers' milk, are fed upon such cows' milk as is 
brought into cities; upon gruel, and the various compounds called 
pap or children's diet. 

The food for a child is the milk of a woman, not that of a cow, 
or a goat. — This proposition proves itself— it is self-evident. — 
Therefore, when the physician is called to such a case, one of 
the clearest items of his duty consists in this, namely, to return 



84 JAUNDICE. 

the child under the influence of the laws of nature as to its diet, 
by directing to be procured for it a proper breast of milk, and 
forbidding utterly the exhibition of those wretched compounds, 
which, even the best of them are, after all, but miserable suc- 
cedanea for a generical mode of alimentation. Where the cir- 
cumstances of the parents will not allow the procuring the breast 
of milk, then the succedaneum must be submitted to. As I 
have already expressed my opinions as to the best modes of arti- 
ficial alimentation, I have no occasion to speak again of that 
subject in this place. 

Although mothers' milk is the proper aliment for the child, this 
it not true of every mother's milk; the milk of some women being 
poisonous to the infant — that, for example, of a woman who in- 
dulges in the use of strong alcoholic potations, cannot be salutary; 
she who labors under some vice of her constitution, whether 
tuberculous, carcinomatous, scrofulous, or other, is not fit to be 
entrusted with the alimentation of a new-born child. She who 
is subject to violent fits of passion, or attacks of hysteriform ma- 
lady, produces milk which has in some instances been capable of 
casting the child into convulsions, and, a fortiori, of disordering 
its digestion. 

In making out, therefore, the ordinances for the child, whether 
they be therapeutical, or whether they be hygienical, it behoves 
that an intelligent inquiry should be made into the nature and 
condition of the mother's milk, which, if both expedient and pos- 
sible, ought to be changed for that of another w^oman. But even 
in feeding the child upon milk undeniably healthful, very careful 
directions should be given as to not overloading the stomach by 
too frequent indulgences, or too long continuance at the breast, 
as I have before pointed out. 

In the very young child, one has a natural aversion to the ex- 
hibition of emetic doses, which seem to be too rough and too 
rude a therapia for so young a creature; nevertheless the young 
child vomits easily, and apparently without suffering so great a 
constitutional shock as is occasioned by a similar operation in 
the adult. Whenever the action of an emetic might be deemed 
useful, with a view to its power to emulge, as it is called, the 
excretory ducts of the liver, and to liberate the stomach from the 
thraldom of a mucous acid saburra, it will be quite lawful to ex- 
liibit an emetic, in the form of the wine or the syrup of ipeca- 



JAUNDICE. 85 

cuanha, of which a few drops are given from time to time, espe- 
cially if diluted with water; or, a weak infusion of chamomile 
would suffice to bring about the desired effect — or two or three 
grains of alum powder, mixed in a small quantity of honey slightly 
diluted with water, furnish us with an emetic dose as safe as a 
common salt water emetic; one which is, moreover, very prompt, 
and capable of exercising a salutary influence upon the mucipa- 
rous follicles and glandules of the stomach and duodenum. 

As to purgatives, they may consist of infusions of rhubarb, or 
the simple or aromatic syrup of rhubarb; of magnesia or cas- 
tor oil. They are administered not unfrequently, with a view 
first of exciting, and thereby steadying the peristaltic muscles, 
while they, at the same time, serve to free the child from an in- 
testinal saburra of acid and phlegm, of imperfect bile, and re- 
sidue of digestions, the which, being gotten rid of, it appears 
probable that the capillary circulation of the distal branches of 
the digestive arteries, as well as the capillary circulation of the 
hepatic portse, will be set at liberty to obey the more healthful 
laws of their several innervations. 

In this view these simple purgatives present to us the exam- 
ples of most admirable alteratives; but, if the physician, unsa- 
tisfied with such a view" of an alterative, should feel that he 
must resort to the alterative par excellence^ let him exhibit ca- 
lomel, or chalk and mercury, or the common blue mass, to be 
followed soon afterwards by one or another of the aperients be- 
fore mentioned. It is probable indeed, that calomel, and other 
preparations of mercury, are endowed with an alterative power 
more potent than that appertaining to the above-mentioned 
lighter medicaments. No one, I believe, pretends that the far- 
famed alterative qualities of mercury are chemical qualities, and 
I believe that if it be- really possessed of an antiphlogistic or an 
aplastic force, as they affirm of the articles of its kind, we ought 
to attribute it to the impression which it produces upon the sen- 
sitive nerves of the primal vise, modifying thereby their innerva- 
tive force as expended upon the capillaries, the absorbents, and 
the excretory apparatus of this system of tissues. 

Such modifications as these articles may introduce, cannot fail, 
it is evident, to produce changes, whether good or bad, whether 
useful or the contrary, in the rate of the secretions, and it ap- 
pears to me very clear that melioration as to the quality or the 



ISO JAUNDICE. 

quantity of the secreted products of the liver, as well as of those 
of the alimentary tube, gives us just ground to hope for equal me- 
liorations of the condition of the nervous, muscular, and mem- 
branous portions of these solids — the object to be held in view by 
the therapeutist. 

With regard to the state of the bowels in the young child, it is 
not to be expected that after biliary evacuations have been pro- 
duced by the influence of the alteratives which have been above- 
mentioned, at least, it is not always to be expected that the child's 
health will be speedily restored ; because irritation or debility of 
the stomach and duodenum may continue to admit of the develop- 
ment of too great quantities of gastric or intestinal acid ; or there 
may be left in a portion of the intestinal tractus, an irritation of 
the muciparous follicles and glands, giving rise to abundant mu- 
cous secretions, which communicate to the stools a character of 
disorder, and the presence of which must interfere with the ab- 
sorbing, as well as the digestive functions, of the alimentary appa- 
ratus. 

We have the power, by means of various therapeutical articles, 
to quell this production of acid in its nascent condition. These 
means are the alkalies, such as potassa, soda, lime water, ammonia, 
prepared carbonate of lime in the form of the creta preparata, pre- 
pared oyster shell, chelae cancrorum, and oculi cancrorum. The 
exhibition of such articles as these, with bitters and astringents 
of various kinds, enables us to rescue the child from the trouble- 
some consequences of gastric and intestinal acid, and mucous 
saburra of the alimentary tube. For the patient within the 
month, doses consisting of two grains of bicarbonate of potassa, 
repeated two or three times a day, may be safely resorted to, or a 
similar quantity of bicarbonate of soda, or teaspoonful doses of 
lime-water diluted with an equal quantity of milk, or two or three 
grains of chelse cancrorum, or oculi cancrorum, combined with 
five or six drops of tincture of krameria, or tincture of kino, con- 
stitute useful and safe combinations. 

Under theise circumstances, also, if it be found that the peris- 
taltic fibres of the intestine be irritated, or easily thrown into vio- 
lent spasmodic contraction, it is salutary to administer some por- 
tions of tincture of opium, of which the dose to a child, within 
the month, ought not to exceed half a drop. 

And, finally, by expecting the child to improve, we often find 



JAUNDICE. 87 

it to improve. It is doubtless necessary that the physician should 
carefully inquire whether there be really a necessity for therapeu- 
tical prescription, and where such a necessity is found to exist, he 
ought not to abstain from it, but I conceive there are many cases 
in which he deems himself called on to prescribe, which, with a 
little patient expectation, he would find to pass by without the 
administration of any medicines. 

It is not to be denied that the homoeopathists have, in these lat- 
ter years, had the care of many sick persons, who have recovered ; 
many of them, from severe or threatening maladies under their 
supposed therapeutical treatment, consisting of the administration 
of decillionths of a grain which are equal to nothing ; it is clear 
that their patients, when they do recover, owe their recovery to 
expectancy. 



CHAPTER VII. 

OF THE CHILD'S DRESS, 

The dress of an infant should be adapted to the climate. 

In the climate of Pennsylvania, we have great and sudden tran- 
sitions of temperature, during all seasons of the year ; and the 
difference between winter and summer is extreme. 

It is clear that young infants should be sufficiently protected 
against the cold of winter, and guarded against the morbific tend- 
encies of sudden revulsions of the weather in spring and autumn ; 
while it should be dressed in such a way as to add nothing to the 
debilitating influence of our protracted intense solar heat and 
light in the warm season. 

In many families not the least difference is made in preparing 
the dresses of children to be born in February, or in August, 
which is plainly an error in hygiene not less gross than would be 
the applying of the same sort of habiliments to the children of 
Senegal, and those of Nova Zembla. 

Certainly, I have reason to think that thousands of lives are 



88 DRESS. 

annually sacrificed to mere fashion in the dress of new-born chil- 
dren ; whether of those that are born in the hot, or of those that 
come into the world in the cold season. 

An infant should, after the first of June, here, and earlier in the 
southern states, be clothed in its belly-band, a flannel shirt, and 
a light frock low in the neck, and with long sleeves. A cotton 
sock should cover the foot. It requires no cap; but, when sent 
out for exercise, in the nurse's arms or in the carriage, it should 
be covered wuth a light surcoat, and hat or bonnet. 

Those that are born after the 20th of September, and previously 
to June, should have in addition to the belly-band, shirt, and 
flannel petticoat, a frock high in the neck, with sleeves to the 
wrist, and long worsted stockings for the legs and feet. 

It is difficult, I might say it is impossible, for a physician to 
oppose with general success, the powerful dictates of fashion or 
custom ; and it will happen, therefore, that in a multitude of in- 
stances, in which he may experience a great degree of solicitude 
for the welfare of the young children of families under his medi- 
cal care, he shall in vain recommend precautions as to dress, that 
seem not to coincide with the general opinions of society. In 
arguing in favor of his plan, he is sure to be met by the unan- 
swerable argument that such and such children are dressed in 
the style to which he objects, and that it is impossible to see finer 
or more healthy children. 

Many times w^hen I have witnessed the pernicious or danger- 
ous effects of improper modes of dress, as to certain children, I 
have found it bootless to persuade to a reformation of the style, 
because other children have not required the adoption of such a 
plan as that recommended. The cases are beyond computation, 
of attacks of illness, and of fatal seizures clearly attributable to 
the faulty methods of dressing used in the United States. 

In Europe, the young children are clothed with dresses that 
come up to the throat, and that cover the arms quite down to the 
wrists. 

Our aboriginal mothers always cover their infants to the throat, 
and I have seen many Cherokee, Ottawa, and Chippewa infants, 
even in warm weather, completely protected, except as to the head, 
which is left naked. 

In Pennsylvania, the mutations of temperature are frequent and 
sudden, and violent; changes of thirty or forty degrees within a 



DRESS. 89 

period of twenty-four hours, being not very rare. Yet we find 
that the potent spell of custom and fashion induces a majority of 
our women to leave exposed nearly a moiety of the thorax, and 
almost the whole of the arms of the young child, at all seasons. 

Assuredly, if any portion of the infant really requires protection, 
it must be those parts of the body that are least profusely supplied 
with arterial blood ; and, since most of the blood of the arm is 
injected through the axillary artery, it is manifest that cold and 
damp can more readily exert their morbific and repercussive in- 
fluences on a part so imperfectly injected by the heart, and so 
remote from the common source of the circulation and heat. 

The brachial artery of a neonatus is a very small vessel, and 
the cold surface of an infant's hand and whole arm, cannot but 
require a perpetual effort of reaction against the evil tendency of 
the exposure. Such efforts of reaction, occurring in children 
irritable, of feeble constitution, having weak bowels, or prone 
to catarrhal disorders, are dangerous in the extreme ; for in all 
such, it is only necessary to light the torch of fever in them, in 
order speedily to develop all the phenomena of inflammation. I 
am very confident in believing that great numbers of little chil- 
dren have had occasion to be put under medical treatment in my 
practice, solely because of the improper, imperfect, and dispro- 
portioned dresses in which they were clothed. 

It is a common rejoinder, that of saying, the child must not be 
brought up too tenderly, and that it must be hardened. This is 
true; for, if a child be very warmly clad, and be also kept in 
well-warmed apartments, not properly ventilated, it cannot fail to 
acquire an hypersesthetic habit, which is perilous in the extreme, 
for in that case it becomes obnoxious to almost every etiological 
provocation. 

To such a rejoinder, the reasonable answer is, that the infant 
should be first well clad, and then daily exposed to the atmosphere ; 
that men and animals were designed to live sub-dio — in the open 
air; and that it is incompatible, as a common rule, with good 
health, to be excluded from the influence both of solar light and the 
common atmosphere. Exercise, fresh air and insolation, though 
less indispensable than food* come next to it, in the order of the 
hygienical requisites. I therefore, in all cases, except in those 
of sick children, advise my friends to send their children to walk 
or ride in all weathers, believing, indeed, that even rain and 



90 ' DRESS. 

snow, and sleet, are insufficient causes for detaining a healthy 
infant in doors and in close rooms, for twenty-four consecutive 
hours. To dress a child like a fantastic doll, and shut it up, ex- 
cept in the most inviting weather, is, in my opinion, a serious 
error. The same child, properly dressed, might be safely sent 
into the open air even in a tempest. 

As to the dresses of children in sickness, common sense dic- 
tates their adaptation to the cases. 

In all families, where poverty does not forbid, there should be 
provided for each child at least one sick wrapper, a dress open in 
front, like a dressing-gown, provided with strings or buttons, to 
close around the neck, and with sleeves reaching to the wrist. 
For winter-service, such a wrapper should be double, with strings 
round the waist, that it may be conveniently and perfectly closed, 
so as to afford the most complete protection of the surface against 
direct atmospheric contacts, a protection most desirable in the pul- 
monic and intestinal disorders of young children, as well as in 
their exanthematous disorders. It is preposterous to see a child 
with hurried and laborious respiration, bandaged and pinioned by 
its ordinary day-dress ; when, in fact, it most urgently requires 
that all obstructions to the play of the functions be carefully 
eschewed. 

In numerous instances, where I have been summoned to advise 
for children attacked with measles and with scarlatina, I have 
immediately directed a nightgown to be made of flannel, and that 
long enough to reach quite down to the feet. Such a night-gown 
close in the neck, and with, sleeve buttons at the wrist, gives 
admirable protection to the whole dermal surface, and offers no 
obstruction of pressure or ligation anywhere. 

Children dressed in such gowns will, cceteris paribus, go more 
safely through such disorders than those that are dressed other- 
wise; for the danger in these maladies refers almost as much to 
the tendency to take cold as to the direct febrile and inflammatory 
provocations of the causes. And though the danger of taking 
cold decreases rather with the period of decline and cessation, 
than with those of the attack and persistence, yet it is true that 
no trifling ratio of the fatalities in them are chargeable to sup- 
pression of the transpiration after the danger had apparently dis- 
appeared. 

Such a flannel dress as I have recommended affords not only 



DRESS. 91 . 

the most perfect and convenient defence against taking cold, but 
it has this other advantage, that as long as it is worn the child 
may be more surely kept under a treatment whether therapeuti- 
cal or hygienical. The sick dress ought not to be removed, until 
every vestige of even the sequelae of the malady shall have com- 
pletely disappeared. 

A few years since, I was in anxious attendance upon a little 
girl, who, as I may remember, was some three years of age. Many 
children of the family had undergone severe attacks of. scarlatina, 
and she was the last one of the series to be attacked. She was an 
only daughter among many boys, and I was therefore the more 
solicitous to conduct her safely through it without accident. 

I caused her deshabille to be carefully provided — put her to 
bed with directions to keep her there for many days after the ap- 
parent malady should have disappeared. But as soon as she was 
free from the rash and the fever, I received solicitations to allow 
her to get up, to which I declined acceding. They were re- 
newed the following days ; whereupon, obliged to waive my rights 
over the case, I imprudently consented to her rising, under a pro- 
mise that she should not leave the nursery. The ordinary dresses 
were worn, which made her the more unmanageable, as she per- 
sisted in demands to leave the apartment, so that upon being so- 
licited again and again, I, in an evil hour of complaisance, said 
yes, provided she should go no further than the dining room, which 
was to be kept closed during her visit to that apartment. The 
weather became cold and damp. — A lady called; the mother 
walked to the front door to say something to the visitor — the young 
child ran to the marble step without a hat or shawl, while the 
friend bade farewell, and that same night I was summoned to 
her bedside to see her nearly dying with peripneumony, which 
doubtless would not have assailed my patient had she retained her 
flannel nightgown, and been kept in bed. The mother detests 
me from that hour, though I think she ought rather to mourn over 
her own folly in abusing the complaisance of a physician to wrest 
from him a reluctant assent to her imprudent and restless desires. 
I have mentioned this case, in w^hich L was very blameable, as 
having yielded my will, not my judgment, under repeated de- 
mands of the mother, not only as illustrative of the importance of 
a proper dress, but as a warning against a too early abandonment 
of it, especially in the great exanthemes; and I have nothing to 
add at present upon the subject of the child's dress. 



92 CYANOSIS NEONATORUM. 



CHAPTER VIII. 

CYANOSIS NEONATORUM. 

I BEGIN by requesting the reader to take notice that the title of 
this article is cyanosis neonatorum, or the blue-disease of young 
children, and that I have no design herein to treat of all the affec- 
tions that may in anywise serve to contravene the aeration of the 
blood — for all such diseases are causes of cyanosis. 

There is so great a variety of maladies that interfere with the 
due aeration of the blood, that a volume, rather than a short arti- 
cle, ought to be devoted to their consideration, in any attempt to 
describe all of them. — Malformation of the heart and its vessels — 
unnatural states of the lungs, whether congenital or accidental- 
tumors — hydropic collections — tubercles — vomicee — congestion — 
inflammation — whatsoever, in fine, prevents the due exercise of 
the whole function of respiration, may be set down among the 
possible causes of cyanosis. My intention is to treat only of 
those cases that are coincident with permanency, after birth, of 
the characteristics of the foetal heart. 

In the four great zoological classes, the mammals, birds, rep- 
tiles, and fishes, the circulation is effected chiefly by the force of 
a compound heart, whose economical purpose is not merely to 
carry on the circulation, dispensing the blood and caloric into 
every part of the system, but in a pre-eminent degree to convey 
oxygen into every part and point of the system. 

In lower grades of being, as in the insects, and annelides, air 
is admitted to the tracheae, through open stigmata on the surface 
of the body. These lower creatures require no mechanical appa- 
ratus or force, to compel the air to enter the interior recesses of 
the tissues. It permeates tubes that are always open to admit 
oxygen to the organic molecules. The higher orders of creatures 
could not exist without a complete machine competent to fulfil 
this indispensable design and purpose. Hence the birds and mam- 
mals are provided with lungs and a double heart, or rather with 



CYANOSIS NEONATORUM. 93 

two hearts, one carboniferous, or venous, and the other oxygeni- 
ferous, or arterial. 

In the reptiles there are, properly speaking, three hearts, of 
which one is venous, or carboniferous, another oxygeniferous, 
and the third mixed, propelling both the oxygenated and the 
undecarbonized blood. In fishes, the heart is absolutely venous, 
consisting of an auricle receiving the blood from the whole body, 
which it delivers into the single ventricle ; whose office it is, to 
inject this blood, in whole, or in part, upon the oxygenating 
surfaces, called branchise, or gills, whence it flows off to the con- 
stitution, to return by the principal dorsal vein, to the auricle; the 
fishes' heart, in this view, may be considered as a true pulmonic 
auricle and ventricle. 

The child in utero, may, as to the nature of its sanguine cir- 
culation, be compared to the fish, or the batrachian. In very 
early stages of its embryonal life^-not the very earliest — the 
heart consists of a double ventricle, equal to one ventricle, and of 
a single auricle. I say one auricle, since the auricular septum can 
hardly be said to exist, and the two auricular cavities are virtu- 
ally one. I also said that it has a double ventricle, each of the 
cavities of which lends its energies to the systemic circula- 
tion. In the beginning, the pulmonary artery — which is really 
a ductus arteriosus — and the aorta equally concur in the produc- 
tion of the systemic circulation; both ventricles being required to 
give impulse to a circulation necessary to the rapid development 
of the constitution, and drive the blood to the distant capillary 
tufts of the placenta and back again to the heart. With the pro- 
gress of the intra-uterine life, the pulmonary artery becomes 
developed upon the ductus arteriosus, which loses by degrees its 
transitive importance, and is laid wholly aside at birth as a no 
longer useful machinery of the circulation. 

The aeration of the embryonal and fcetal blood, depending on 
the placenta, a machinery is required to get the oxygeniferous 
blood of the placental tufts out of the venous into the systemic 
circulation of the child, and another apparatus to turn over its 
venous or carboniferous blood into a part, not the whole, of the 
systemic circulation, w^hich alone can transfer it to the aerating 
tufts of the placenta; therefore, in the child some^vhat advanced 
in its uterine life, there is of necessity a crossing of the currents 
of oxygeniferous and carboniferous blood, in the right auricle, 



94 CYANOSIS NEONATORUM. 

and a direct channel of transfer from the right ventricle to the 
aorta. 

The blood of the umbilical vein, mixed with that of the infe- 
rior cava, enters the posterior, right, lower segment of the right 
auricle behind the right extremity of Eustachi's valve, which con- 
ducts it across the cavity to the fossa ovalis, leading it through 
the foramen ovale. The current lifts Botalli's valve, which is on 
the left face of the septum, to pour itself out into the systemic 
auricle. The left ventricle receives it, and thence it is conducted 
by the carotids and vertebrals to the encephalon. 

This is the best blood of the foetus. It is not highly aerated ; 
probably, not so highly as that of the Reptilia, consisting as it 
does of the deoxygenated blood of the portal circulation, and of 
that of the lower extremities and pelvis, and animated only by 
the slight endowment of oxygen it could acquire in the pla- 
centa, from whence it is derived by the umbilical vein. 

Imperfectly aerated as it may be, it is to a certain extent, tjie 
oxygeniferous fluid of the foetus, and is capable of developing 
the torpid innervations of the embryo and foetus, which are, per- 
haps, far inferior in intensity to those of the chelonians and other 
Reptilia ; doubtless, far inferior to those of many tracheal creatures 
and infusorials. 

Having made its route to the encephalon and superior extremi- 
ties, where it has given out its oxygen, the blood has become tho- 
roughly venous, and returns to the right auricle, into w^hich it 
plunges at the superior part of the sac, in front of Eustachi's valve, 
and opposite to the iter ad ventriculum dextrum, through which it 
flows, while the current from the inferior cava passes through the 
foramen ovale behind it, and at right angles to it. 

The right ventricle is filled then with the venous blood of the 
head and upper extremities which it injects, by the pulmonary 
artery, virtually the ductus arteriosus, into the aorta, below the 
giving off' of the carotids and subclavians. Thus it arrives again 
at the placenta. 

In this crossing of the currents in the auricle, there is a par- 
tial mixture, but it is presumed to be only partial. 

It is probable that a major part of the blood from the ductus 
venosus, mixed with that of the hepatic veins and inferior cava, 
is directed upon the head and superior extremities, though it is 
true that a portion of it turns over the aortic arch to be mixed 



CYANOSIS NEONATORUM. 95 

with the current from the ductus siJfteriosus. It is, indeed, essen- 
tial that this should happen, since otherwise, the Avhole of the 
digestive, renal, and pelvic branches, as well as those of the in- 
ferior extremities, would otherwise be asphyxiated. 

This admirable arrangement, by which the systole of the left 
ventricle propels both the arterial blood to the brain, and the 
venous blood to the placenta, must necessarily persist throughout 
the gestative life ; for, should it cease previously to the birth, the 
foetus would inevitably perish, while its persistence after birth, 
would be equally fatal. 

The foramen ovale affords the sole normal route of the arterial 
blood from the placenta towards the brain. 

Hence, the foramen ovale is persistent in the fcetus. 

Hence, also, the child is born with an open foramen ovale. 

But the foramen is provided with an operculum or valve. 

The valve, called valve of Botalli, lies upon the left wall of the 
septum auricularum. 

WTien the valve is shut, the opening is closed. The lifting of 
the valve re-opens the aperture. 

If the valve be closed before the establishment of the respira- 
tory life, the child dies from absence of oxygen in its brain, for 
the oxygen of the placenta cannot reach the brain by any other 
route. 

The valve remains open for many days after the birth of the 
child, three, ten, twenty days; and it may be open seventy years 
in some cases. 

As in the uterine life, aerated blood passes through the foramen,, 
so in the respiratory life, carbonated blood, if any, passes through 
the opening, to fill the left auricle. Whenever the left auricle is 
filled with venous blood, it is injected by the systemic ventricle 
into the brain and whole system. 

Such injections produce cyanosis. Cyanosis is a state of 
non-aeration, more or less complete and universal. Cyanosis of 
the capillary system of the brain, is true asphyxia. 

The degree of intensity of the blue color in cyanosis, is not a 
certain criterion of the effect produced by the malady. 

One individual may tolerate a greater degree of cyanosis than 
another, with less inconvenience and distress than that other in- 
dividual. 

I repeat that cyanosis, whether general or local, is a degree of 



96 CYANOSIS NEONATORUM. 

asphyxia of the parts exhibiting the phenomenon. Blue hands 
from cold weather, blue finger-nails from ague, from cholera, 
from drunkenness, or etherization, is asphyxia of those parts 
severally. Asphyxia of the capillaries of the skin, or of the ex- 
tremities, is not inconsistent with life. But, asphyxia of the 
encephalic capillaries, when carried to a certain extent, is mor- 
tal. Mortal asphyxia is always so, because the capillaries of the 
brain are the seats of the malady. 

This I consider to be true, because the asphyxiation of a limb 
by means of the tourniquet, is not suddenly mortal, it does not 
speedily destroy life — it only arrests development, whereas car- 
boniferous blood in the capillaries of the brain destroys life in- 
stanter, if it be wholly and only carboniferous. 

Many children at birth, or soon after delivery, discharge the 
blood of the right auricle into the left auricle, in consequence of 
asynergic or asynchronous action of the heart. 

In such cases, to shut down the operculum or valve of Bo- 
talli, is to arrest the flow and cure the patient for the time being, 
or for all future time. 

In November, 1832, the year of cholera, I had charge of the 
case of Mrs. Taylor, No. 503 North Fourth Street. She was 
about seven and a half months gone with child, when she was 
seized with symptoms of the prevailing epidemic. She was vio- 
lently attacked, and became also affected with symptoms of pre- 
mature labor, which at length led to the expulsion of the foetus. 

The child was alive, but began to turn blue under its respira- 
tion. As the cyanotic hue became more intense, the phenomena 
exhibited by its innervative forces, turned more and more unnatu- 
ral, so that, employing only faint and imperfect aspirations, often 
suspended; becoming convulsed, and having feeble, scarcely per- 
ceptible pulsations, it seemed at the point of death. 

The young mother, who was still ill with her cholera, could 
not be insensible to the danger of the child, and I perceived that 
the complication of a psychological with her other irritations, 
might render the cure of her own malady more difficult, if not 
impossible. It became, then, in view of the mother's position, 
a matter of great moment to rescue the child from an apparently 
imminent death. These reflections, which I made at the time, 
gave me great pain ; — for, while I deemed the state of the child 
one of partial asphyxia from the mixture of its venous with its 



CYANOSIS NEONATORUM. 97 

arterial blood, the mixture being made by injection through the 
foramen ovale of the auricular septum, I could devise no treat- 
ment upon which to rely for obviating that injection. 

I was deeply concerned, and knew not what to do ; suddenly 
I reflected upon the structure of the foetal heart, and the route of 
the foBtal circulation, and I said, if I bring the septum auricula- 
rum into a horizontal attitude, will not the blood in the left au- 
ricle press the valve of Botalli down upon the foramen ovale, and 
thus save the child, by compelling all the blood of the right 
auricle to pass by the iter ad ventriculura, and so to the lungs to 
be aerated? 

Having practised midwifery for many years, I had on many 
occasions witnessed the fatal termination of cyanosis neonatorum, 
both in the premature and the mature child. I had seen children 
at five, and at five and a half, at six, and at seven months, vainly 
attempting to carry on respiratory life, and found them all to perish 
with the signs of cyanosis, whether from too large a foramen 
ovale, or from imperfect development of the respiratory machinery 
of the lungs by atelectasis. 

In the case now under consideration, I placed the child, which 
seemed nearly dead, upon a pillow, on its right side, the head and 
trunk being inclined upwards about twenty or thirty degrees. 

Upon placing it down in this manner, it became quiet — began 
to breathe more naturally; to acquire a better hue of the face, 
hands, and feet ; until, in a very short time, it was quite well again, 
and did well; having no further returns of the attack of cyanosis 
neonati. 

I shall not conceal the satisfaction I derived from the success- 
ful result of my reflections, thus put into practice in the case ; for 
I thought, and I still think, that the child would have died inevi- 
tably, but for the treatment. In very many instances, during a 
long obstetric experience, I had never made such a reflection 
upon the means of saving the blue child, of which I had seen 
so many cut off". I believed, and I still believe, that I was the 
first to invent the treatment; and thus the first case in which I put 
it in practice, was eminently successful. I am not aware that 
any other person had before suggested it, though in his account 
of cyanosis, M. Gintrac gives in case 5th an account of Dr. Wm. 
Hunter's patient, set. 8, who obtained relief from a paroxysm, by 
lying still upon his left side, which always relieved him. After 
7 



98 CYANOSIS NEONATORUM. 

his death, the ventricular septum was found to be wanting, or 
rather perforated near the base of the heart, so that the aorta re- 
ceived the injection of the right, as well as of the left ventricle. — 
Vide Gintrac, p. 33. 

Six years later, in my Piiilad. Pract. of Mid., edit. 1838, I 
published some remarks on cyanosis, or blue-disease, which,, 
being written in much haste, I did not at the time remember the 
circumstances of the above case, which occurred in Nov. 1832, 
in Fourth Street above Poplar Street, No. 503, in a child of Mr. 
Taylor, a builder, formerly of this city. 

Since the date of my first application of this method, I have 
had numerous occasions to put it in practice, and not a few op- 
portunities of examining the state of the heart after death, in 
some of which, after vainly applying the treatment, I came to the 
conclusion that other causes, not patency of the foramen ovale, 
must exist, to contravene the curative tendency of the method. 

My publications — and my explanations to friends — with the 
lectures on the subject that I have now delivered to many hun- 
dred students of medicine, have rendered my treatment a popular 
one, — to such an extent, that, in various states of the Union, the 
treatment is become a familiar one. Many monthly nurses have 
become acquainted with it, and I presume it is so divulgated 
throughout the land, that children suffering from the malady will 
very generally have the advantage of its application, if it be 
really advantageous, and this the more probably, since no reason- 
able objection could be found to the putting of it in practice. 

I make these remarks, founding them upon various letters I 
have received from gentlemen in the different states of the Union; 
from conversations, and from statements made to me by medical 
students on their arrival here, in the autumn, of cases treated by 
their instructors. 

This explanation will show that I am w^ar]*anted to say, that my 
invention has become extensively known, and is to a reasonable 
extent understood and practised in this country; the more espe- 
cially as it has been reported by many hundred medical students, 
that are now settled in the north, the south, the east, and the 
west. 

I have now before me a letter from Paul F. Eve, M. D., Prof, 
of Surgery in the Medical College of Georgia, dated Augusta, 
Feb. 2, 1848. In this letter, Dr. Eve informs me that he was 



CYANOSIS NEONATORUM. 99 

In attendance 22d Nov., 1847, upon Mrs. C, then affected with 
premature labor of an uncertain date of gestation. The child, 
a male, which was born after an easy travail, weighed between 
five and a half and six pounds. The testes w^ere not yet in the 
scrotum. The respiration w^as at first carried on by sighs repeated 
once in five minutes. The child was once supposed to be dead, 
and given up as lost ; but by breathing into the lungs it re- 
vived, and then upon being laid upon its right side, where it was 
kept during four days, it perfectly recovered, and was healthy 
at the date of the letter. It was not dressed for three days. 
Every motion, for some time after its birth, would produce the 
cyanosis. Dr. Eve is inclined to believe it w^as six and a half 
months in the v/omb. 

In March, 1848, 1 attended Mrs. G. T , who w^as at the time 

delivered of a child at six months and ten days. It was deeply 
cyanosed for four days after its birth. The nurse kept it almost 
wholly reclined on its right side, and the infant, now about three 
wrecks old, presents a good prospect of a successful rearing of 
it. In this case, the child was certainly relieved w^hen laid upon 
the right side. 

In the early part of the present year, I delivered Mrs. , 

Thirteenth street, of a fcetus at six months. It breathed well at 
first, and uttered loud cries. But cyanosis came on the third day. 
I many times caused the livor to disappear by turning it on the 
right side, and made it return by rolling the child gently over to the 
left side, and vice versa, as often as I repeated the experiment. It 
died after some days. The foramen ovale w^as slightly open, and 
the lungs partially affected wdth atelectasis. 

Here is another letter, dated Antrim, Allegheny County, Penn., 
Feb. 11, 1848, which was addressed to me by Dr. S. Schreiner, a 
graduate of the Jefferson Medical College. 

"Mrs. A. Slatter was delivered on Tuesday, Jan. 11, 1848, at 
7 P. M., of a male infant. Nothing peculiar transpired during 
the gestation or delivery. Parents healthy; mother quite lusty. 
Supposed weight of the child about eight pounds; it seemed of 
full age, healthy, and well to do. About 9 P. M., it seemed to 
have a violent attack of colic ; cried violently. All attempts to 
pacify it were vain, until about midnight, wdien it became quiet, 
and w^as laid in bed behind the mother, where it remained until 
about 8 A. M. on Wednesday. At that time the mother aw^oke, and 



100 CYANOSIS NEONATORUM. 

thinking it breatlied strangely, asked the nurse to take it up, to 
see what was the matter. She did so, and observed that it was of 
a dark-purple hue ; the breathing seemed to cease ; it was strongly 
convulsed, the fingers being clenched firmly against the palms of 
the hands." 

Dr. S. informs me that the child was now removed from the 
lying-in chamber, in order that the mother, after she had been 
told it was dying, might not witness its last agonies. 

"Upon remaining so for some time, it gasped for breath, the 
purple discoloration faded from it, and the paroxysm was over. 
It remained quiet, without any motion whatever for about three 
hours, when the fit returned again ; and again it did so, each 
paroxysm continuing longer and increasing in intensity until 
Thursday (the. following day), between four and five P. M., at 
which time I first saw it. During this time it had seventeen at- 
tacks, the duration of the last one being over forty minutes. The 
attacks returned at intervals of a little more than an hour. 

" Its appearance, when first seen, was as follows. It laid motion- 
less upon a pillow in the nurse's arms ; pulse irritable ; cheeks suf- 
fused with a scarlet flush ; respiration short and quick ; (it seemed 
as if fever was present ;) dusky color of the skin, except the bright 
spot on the cheeks. Soon its face, then its body and limbs, be- 
came of a dark purple or nearly black color; respiration, a short 
gasp at long intervals, gradually increasing until it was altogether 
suspended for twenty minutes; pulse grew fainter and fainter, 
until it ceased at the wrist, and the heart only gave a heavy throb 
at long intervals. Gradually the pulse became (again) percepti- 
ble at the wrist — the discoloration vanished, and the paroxysm 
was over. 

"Though the parents and all present declared there was no use 
in attempting anything for its relief, they consented that a trial 
should be made. I had it laid in the position recommended by 
you in your course of lectures, and in your Phil, Prac. of Mid., 
upon the right side, at an angle of 30°, enjoining strict adherence 
to the position. 

"From its flushed appearance, and the congestion seemingly 
present, I should have recommended leeches, had they been at 
command. I remained long enough for another paroxysm to 
have taken place, judging from the previous intervals, but it did 
not take place. During this time it attempted to cry, but made 



CYANOSIS NEONATORUM. 101 

no sound -whatever, though it seemed to cry violently. After this 
it passed some meconium, and took a little milk and water which 
it sucked from a rag placed in its mouth. I was told these were 
the first motions of the kind it had made for tw^enty-four hours. 
They had before poured some nourishment down its throat, but it 
appeared to bring on a fit, and they desisted. I saw it again the 
next morning. It had two returns of the disease; so very slight, 
however, as only to be observed by the face becoming darker ; 
but they continued only a few minutes. I should not forget to 
mention, that after each of these, perspiration ensued ; slight at- 
tacks first, but after the second very copious. 

^' Pulse at this time appeared normal; respiration easy, but 
somewhat quick. I saw it again to-day. Has had no return of 
the paroxysm, and is in excellent health, with the exception of an 
occasional attack of colic." 

I shall now oflfer some observations on the circulation of the 
blood, in order to sustain the position I have taken as to the influ- 
ence of the child's attitude in curing it of an attack of cyanosis 
neonati; and I shall do this, not merely to defend my opinion 
and practice against the opposition of those who deny the utility 
of the precept, and the reasonableness of its doctrine, but because, 
while it has been, in my hands, the means of rescuing many 
children from death, it has also led me to entertain views of the 
pathology and treatment of certain disorders which I desire now 
to explain, hoping they may become useful to the public, and to 
my brethren generally. 

In contemplating a living body, w^e are struck w^ith the con- 
viction of its complex nature and attributes. We behold it as 
consisting of various parts and organs, each endowed with powers 
of its own, and each charged with some especial function, the 
due and harmonious exercise of which by all the organs represents 
a state of health, while an imperfect or irregular performance of 
any of these offices is indicative of a condition of derangement, 
disorder or disease. 

In contemplating such a being, in whatever grade of the zoo- 
logical series it may be stationed, we are compelled to admit that 
of its parts, some are of more and others of less importance. It 
has parts that might truly be called noble, and others that are 
common or vile. Whether it be an annelide, or insect, a radiate, 
vertebrate, reptile, fish, bird or mammal, the EnSj the living 



102 CYANOSIS NEONATORUM. 

creature, the Verb — that which can do, be, or suffer, of it, is 
composed of the nervous mass of the creature, which is noble, 
and all the rest is vile, common and of less account. 

To look upon the Figures at page 4 of Milne Edwards' vo- 
lume on the Invertebrata, wherein he has represented the nervous 
system of an earwig, a grasshopper, &c., one sees the real ab- 
stract animal, deprived of all save its nervous mass, which alone 
is the patible, sensitive, and perceptive being, while all the rest 
of the constitution of it being taken away, it has thereby lost only 
its servitors — its prehensile, locomotive, digestive, reproductive, 
aerating organs. The nervous mass — the creature — the Ens, is 
left entire — naked — alone, in an abstract state. 

This idea of a creature, abstracted from its armature, its en- 
gines and agents, is by no means a novelty, and it has the sanc- 
tion of the wisest men — such as Cuvier, Lorenz Oken, and 
others. It is upon this idea of the creature, as consisting essential- 
ly of the nervous mass, that all modern zoological classification 
depends, and in fact, the whole regne animal of the illustrious 
French naturalist has derived the exact method and order of its 
arrangement from a view of the disposition of the nervous system 
of its integral individuals. In the higher orders of the vertebrata, 
the number and magnitude of the organs are greatly augmented 
above those of the simpler existences. A medusa, an actinia, a 
holothuria, or a polyp, is equally, with the most elevated mam- 
mal, composed essentially of a nervous mass, which in some with- 
out, and in others with a centrical sensorium, exists either by means 
of disseminated nerve points, or by a ganglionic and filamentous 
system of innervations. 

In the human being, the nervous mass is the cerebro-spinal 
axis, and the sympathetic and plexual system, with all the nerve- 
fibres that blend their distal extremities, or reflect their fibrillse in 
the substance, or on the surfaces of the tissues. The heart itself 
and the stomach are but portions of the nervous mass, enveloped, 
like the gem in geology, in the gangue of the cellular, muscular, 
mucous, or fibrous tela. 

The same is true of the alimentary, respiratory, secretory, 
absorbent, sensual, and reproductive organs — of which an ulti- 
mate anatomy ought to seek to expose and make manifest solely 
the nervous portion of its mass. 

The whole brain and cord — the pneumogastric, the trifacial^ 



CYANOSIS NEONATORUM. 103 

and the phrenic nerve — all the arches of the great sympathetic — 
every ganglion, plexus, and fibrilla, are either conductors or 
generators of biotic force. 

But, whether conductors or generators, it cannot be denied that 
they are in a degree generators, since all nervous mass is a gene- 
rator. 

In either case, the material vile parts which they innervate, owe, 
not their existence only, and their development to the nervous 
mass within them, but every modification of their vitality, every 
shade of their life modality, may be assigned to a status of the 
supplying and sustaining nervous mass. 

In the series of creatures, rising from the lowest infusorial, we 
find at the summit of the scale, man with his concentrated cere- 
bral, or certbro-spinal nervous mass, by means of which he is 
rendered capable not only of impression, but of conscious per- 
ception, and of free-will; of reason and judgment, w'ith all the 
powders of the intelligent mind. 

It is for the conservation of this nervous Ens — this nervous 
mass, as Oken denominates it, that its servants and ministers the 
anatomical organs and histological tissues are added to it, as its 
endow^ments and properties. IT is the seat and source of their 
vitality. They are regulated and maintained in a co-ordinated life 
by ITS biotic force. 

When that biotic force fails, they fail likew^ise ; when it dies, 
they also perish ; when it recovers its energy, they resume their 
powders, and perform their offices for its conservation— its protrac- 
tion — its sensation — its consciousness — its free- will — its reason — 
judgment, imagination — its hope and its charity — its fore-thought 
. — its retrospection — its self-complacency, and its remorse. 

But what is this nervous mass? 

Oken says, "The origin of the animal is from the nerves, and 
all anatomical systems are only free evolutions or separations from 
the nervous mass. The animal is naught but nerve ; what it 
is further, or in addition, is obtained elsewhere, or is a metamor- 
phosis of nerves." "When, also, the other systems have been 
formed out of the identical nervous mass, still the whole animal 
body is naught but nervous mass, only, in a crude or inert condition. 
There is, consequently, no point upon the body, on which some 
nervous phenomena are absolutely wanting, or where they may 



104 CYANOSIS NEONATORUM. 

not appear, under certain relations." — Physio-philosophy, page 
330. 

I shall not encumber' these pages with quotations from the 
authorities, to fortify the assertion that the nervous mass is the 
essential Ens. The asseverations of a thousand philosophers 
would not make more or less true, a proposition which commends 
itself to the mind, acting upon its own perception and judgment 
of a dogma declared to be true. Such a truth is not proved by 
evidence, nor established by any method of induction. It is a truth 
of reason — it is a truth of consciousness— it is in the same cate- 
gory with the cognition of our personal identity. 

Taking the dogma for granted, therefore, I shall proceed to 
show that the cerebro-spinal axis in man, is inert and powerless, 
nay, lifeless, exanimate as of itself; and that it depends upon the 
influence of oxygen for its power to manifest itself in its life-phe- 
nomena. 

The same Oken has said that " the blood is the fluid body ;" and 
that "the body is the fixed and rigid blood." 

These expressions are equivalent to the assertion that the his- 
tological materials of the body are derived from the blood, and no 
one will deny the proposition. Even the nervous mass itself is 
developed and maintained in volume, form, and weight, by sup- 
plies from the sanguine mass; but the oxygen of the blood is the 
agent by which the force of nerves is brought into play. The 
oxygen taken up in the act of respiration, and carried into the 
arterial or aerated blood, is transferred to the brain by the arteries, 
and there its contact or immiscence with the material essence of 
the brain, is followed by the extrication of the power, or nerve- 
force. In this view, an artery is not a mere sanguiferous tube, it 
is an oxygeniferous tube, and it carries that principle everywhere 
throughout the body. 

The respiratory organ, in this view, too, is but the oxygenating 
apparatus, though it thus produces the double effect of endowing 
the blood with its oxygen, and at the same time developing the 
animal heat, while it also eliminates a portion of the somatic car- 
bon. The highest function of the respiration is the oxygenation 
of the nervous mass. 

M. Cerise, in his paper, Sur la Sur Excitation JVerveux, Mem. 
de VAcad. des Sci., avers that to the blood in the brain, is due the 
extrication of the life-force, the nervous force. This doctrine is 



CYANOSIS NEONATORUM. 105 

not true, if hypothecated as of mere blood ; since carbonated or 
carboniferous blood — venous blood in the capillary vessels of the 
brain — is incapable of effecting the least evolution of power from 
the nervous mass. Oxjgeniferous blood is all-powerful for its 
extrication. Hence, since blood, merely as such, cannot gene- 
rate the life-force, while aerated blood can do so with absolute 
perfection; we have a clear inference to the opinion that it is the 
oxygen w-hich is the agent ; and that, by a plain induction of facts, 
all of which, without exception, concur to declare that oxygen is 
indispensable to the exertion of a life-force, force-vitale. — Le- 
benskraft. 

Nothing lives, save in the presence of oxygen. It is even true 
that the spiritual soul being present, all life is a result of a pro- 
cess of oxygenation. Hydrogen azote, chlorine, nor carbonic 
acid cannot evolve nor sustain life. Oxygen is the vitalizing, 
not the vital principle. It is the cosmic reagent for producing 
vitality out of nervous mass. 

Mons. Le Gallois has, at page 142, the following w^ords: — 

^'Life is produced by an impression of the arterial blood made 
upon the brain, and the medulla spinalis, or by a principle result- 
ing from this impression." Also, "The prolongation of life de- 
pends upon the continual renewal of this impression," &c. I 
suggest that arterial blood is not different from venous blood, save 
as containing a larger quantity of oxygen, and that it is the oxy- 
gen, to which M. Le Gallois refers, and not the blood which con- 
tains it. 

If it be not a mere fancy in Oken to say that the " artery is an 
air-tube;" and, if it be true that the blood excites in the brain 
the forces which, irradiating the organs through the nerves, makes 
manifest in them the various motions, and allows in them the 
impressions and perceptions that we suppose to be life ; then it 
is conceded that modifications of the blood, as oxygeniferous, are 
capable of modifying the state of all the organs, and not of them 
only, but of all the histological integers of which the sum of a 
body is composed. Where the blood is healthful and normal, it 
wdll in so far as to a dependency upon the blood, produce a perfect 
innervation, and vice versa. Supposing the blood to consist of the 
four constituents fibrin, discs, albumen and water> in the propor- 
tion of fibrin 3, discs 127, albumen 80, and water 790 to the 1000 
grains — any change in the constituency of the blood cannot but 



106 CyANOSIS NEONATORUM. 

modify its power to take up and carry oxygen to the parts, and so 
to the brain. 

A patient who has suffered from exhausting hemorrhage, whe- 
ther traumatic or active, will, in consequence, be deprived to a 
certain extent of the ability to extricate the nerve-force. 

If, through any faulty arrangement of the great vessels of the 
heart, the venous blood returning from the systemic circulation, be 
thrown back upon the system, without being newly exposed to 
the oxygenating apparatus of the lungs, the nervous mass, failing 
of its supply of oxygen, will fail in part, or die, according as the 
want is less or more incompletely supplied. 

Air, that in a given number of cubic inches contains less oxygen 
than is required for healthful respiration, cannot be breathed without 
diminishing the power to extricate nervous force. Thus a traveler 
ascending a lofty mountain, finds his strength to be diminishing, in 
proportion as he rises above the sea level, and when he is at an ele- 
vation marked by 18 or 20 inches in the barometer, he finds so 
little oxygen in his aspiration, that he is compelled to stop, and 
even to sit down, after walking only a few feet — because the ordi- 
nary aspiration at 16 or 18 inches consisting say, of 20 cubic 
. inches of rarefied air, is equivalent, in the amount of oxygen it con- 
tains, only to an aspiration, perhaps, of 6 or 8 inches at the base 
of the hill, w^here the mercury marks 31. The traveler pants for 
breath, which means to say that he breathes frequently, in order 
to get his required amount of oxygen. That amount which can- 
not be ingested with twenty respirations, he seeks for in forty or 
eighty respirations per minute, for without the requisite amount, 
he cannot extricate the nerve-force, nor will his muscles obey the 
dicta of his free-will — his volition — he is compelled to stop, to 
sit down, or even lie down, whereupon, consuming less of his 
nerve-force, he recuperates for another effort. This was the case 
with the party of Dessaussure on Mont Blanc. 

That which happens to the traveler on the mountain summit, 
occurs to the anaBmical girl at the sea-level. His blood cannot 
find sufficient oxygen in 20 inches of rarefied air; her blood will 
not receive it, though it be contained in the 20 inches. 

But, if the blood be as perfect as possible in its constitution, or 
crasis— and it fail to be exposed to the oxygenating pulmonary 
surfaces, it can by no means excite in the brain those quantitative 
results as to the production of the nerve-force, that are required in 



CYANOSIS NEONATORUM. 107 

all these cases, whether of a low barometry, an anaemia, or a want 
of oxygen; there is failure to supply the essential reagent — the 
oxygen. 

A copper and zinc plate, or a series of such plates, constitute 
no galvanic pile if plunged into milk, or olive oil. They are 
energized by immersion in a saline or acid solution : so, the sub- 
stance of the brain, the nervous mass, has no activity when 
bathed in streams of carboniferous blood ; it is quiescent; it is 
indifferent; it is aperceptive of the presence of such a fluid: but, 
when the oxygeniferous stream of the arterial fluid is injected into 
its tissues, it instantly becomes instinct with life and power under 
the reagent, and streams of biotic force flow off through the nerves 
to all the subject organs; or the free-will has power to urge the 
innervations to their utmost bounds of strength and precision. 

An uninterrupted current of organic innervations, flows from 
the whole nervous mass, whether cerebro-spinal, or sympathetic. 
But there is a free-willing innervative force, that appertains 
only to the great bulbs of the spinal axis. What that free-will is, 
is known to God alone — it is an appurtenant and faculty of the 
soul, whose whole nature is unknown to us. St. Paul admits that 
we know not *^what we shall be," when the soul shall have been 
disenthralled of the shackles and obstructions of the mortal body; 
we know not what we shall be, though we are conscious that we 
shall be. We do know, at least, that we shall be both conscious 
and free- willing existences. These, therefore, are qualities or 
faculties of the soul, exercised through the nervous mass, under 
the force of the great cosmic reagent, Oxygen. 

From the foregoing, it appears that the presence of the arterial 
blood in the systemic vessels of the encephalon and spinal axis 
is asserted to be a requisite for the evolution of the biotic 
force, as far as that force proceeds from the brain and cord. It 
requires no further proof, after the experiments of Wilson Philip 
and Legallois. 

I have already said that numerous explorations of the bodies 
of neonati have shown that the fcetal characteristics of the auricular 
septum are not entirely laid aside until after the third day, and 
often not until after the tenth and the twentieth day; and, that in 
some persons it remains unclosed until the latest date of advanced 
age. It is, however, covered by its valve. 

This may show that there is no inevitable inconvenience con- 



108 CYANOSIS NEONATORUM. 

nected with persistence of the opening after birth, which is a 
physiological, not an accidental, nor a morbid condition; it is 
common to all the placental animals, and in all of them continues 
during a certain portion of their respiratory life. 

In myriads of children, its openness is attended with no incon- 
venience ; nor would any inconvenience result, even in the ab- 
sence of the valve, provided such patency should not be followed 
by mixture of the venous and arterial blood, which could not 
happen under a co-ordinated innervation of the symmetrical 
halves of the heart. Gintrac, page 238, says : Toute communica- 
tion entre les cavites, droites et gauches du coeur n'est pas in- 
evitablement suivie du passage du sang noir dans les voies 
affectees du sang rouge; and, at page 240, he says: " The auri- 
cles first, and next the ventricles of the heart, contract at the same 
instant of time. If their force is equal, and the apertures through 
which the blood is to flow, be unobstructed, the fluid will not 
deviate, one w^ay nor the other; a perfect equilibrium prevails 
between the sanguine columns ; they oppose to each other an equal 
resistance, and each one follows the course naturally belonging 
to it." 

These are undeniable facts ; yet an open foramen ovale is ac- 
cused as the cause of cyanosis neonati. 

Is this a contradiction in terms? Let us inquire. 

The heart is a machine — a hydraulic engine, provided with an 
auricular septum and valve, under which, during nine months of 
foetal life, flows a stream of aerated blood — no one denies it. At 
birth, the stream, in some instances, becomes carboniferous — no 
one denies it. But that venous current cannot but inundate the 
encephalic capillaries, whence all the modifications, not only of 
the hue, but all the strange manifestations as to the nervous force — 
in the respiration — and in the muscular action, calorification, &c. 
&c., that we observe in cases of cyanosis. 

The heart is not an asymmetrical, but it is a symmetrical organ ; 
it has a zygo-zoar nature. In health, the two symmetrical halves 
of it are innervated in the same times, and with equal force or 
intensity. 

But the synergy and the synchronousness may become asynergy 
and asynchronism, under circumstances of disease, or irritation, 
or faulty crasis or constitution, either of the organ itself, or of the 
nervous mass — or of the blood. 



CYANOSIS NEONATORUM. 109 

The heart is the frequent seat of convulsive innervations, or of 
asynergic and asynchronous action. 

If the left auricle should act with greater force, or earlier, or 
more rapidly than the right, the blood in its cavity would press 
down the valve of Botalli, and cause the fluid to escape into the 
systemic ventricle only; but, if the right auricle should act with 
greater force, in earlier time, and more rapidly than the left, it 
is not to be denied that the carboniferous blood would in part, 
and perhaps chiefly, escape into the left auricle, from whence, 
being received into the systemic ventricle, it would hasten to 
deluge the brain, and the whole body indeed, with its non-oxy- 
geniferous streams. Can any one doubt that this was the case in 
the young girl, cited by Gintrac from Morgagni, Epist. xvii. No. 
xii. It is the "first case in Gintrac. A girl died at the age of 
about sixteen years. She had been sickly from her birth ; always 
breathing with difficulty, on account of her extreme w^eakness, and 
always exhibiting a livid color of the skin. The heart was small, 
and with a rounded apex ; the left had the ordinary shape of the 
right ventricle, while the right had the characteristic appearance 
of the left ventricle. But the pulmonary ventricle, although the 
largest, had the thickest walls. The right auricle was also twice 
as large, and more fleshy than the left. Betwixt these two cavi- 
ties, was a foramen ovale large enough to admit the little finger. 
The valves of the pulmonary artery were morbid, leaving an 
opening not bigger than a lentil for the transmission of the blood. 

In this case, the largeness of the foramen ovale may be sup- 
posed to have some relation to the constriction of the pulmonary 
artery, whose constriction preventing the pulmonary ventricle 
from readily discharging itself, equally prevented it from receiving 
freely the discharges from its auricle. The auricle, therefore, in- 
jected the fluid into the left auricle, and thus kept the foramen 
free and large, or, on the other hand, let us suppose that the fora- 
men, being originally so large as to allow of the escape through 
it of most of the blood received in its cavity, there was not left a 
sufficient quantity to keep the orifice of the pulmonary orifice duly 
open. In such case, the orifice of the pulmonary vessel would 
inevitably diminish in size, as in Gintrac's case just mentioned. 

The passage of blood to the lungs, which was not bigger than 
a lentil, prevented a full aeration of the blood, a fault which was 
greatly magnified by the rapid escape of the already carbonated 



110 CYANOSIS NEONATORUM. 

portions that could issue through Botalli's opening, without re- 
turning to the aerating surfaces in the lungs. There was faulty 
injection by the heart. 

Such injection would, lift the light valve of Botalli, whether 
from asynergy, or asynchronousness of the systole; and the con- 
sequence would be a state of partial asphyxia of the child, which 
is what is called cyanosis, morbus cesruleus, or blue-disease. 

In cyanosis, an irregular, imperfect, feeble innervative force 
will show itself in the muscular system of the child, w^hether ani- 
mal or organic; and sudden convulsions, lipothymia, suspended 
respirations, and pulsations, with blue color more or less intense 
and extensive, will complete the picture of the maladive condition. 
The child will be affected with asphyxia more or less complete. If 
the respiratory sources in the cerebro-spinal axis are deluged with 
carboniferous blood to the extent of wholly suspending the biotic 
extrication — death is the consequence — sudden death. 

Cyanosis in this view, is asphyxia, greater or less, according to 
the intenseness of the cyanosis. 

But, the question now recurs, as to what is asphyxia. In my 
opinion, asphyxia essentially considered, is black blood in the ca- 
pillaries of the brain. Some physicians insist that asphyxia is 
black blood in the lungs. I contend that asphyxia is black blood 
in the brain. Asphyxia is a state of the brain in which that organ 
cannot extricate, or give out the life-force — the innervative force — 
the stream or current of nervous force — the biotic force — and I 
contend that it fails to do so, for want of oxygen to react upon the 
neurine. Cyanosis is the sign of the presence of non-oxygenife- 
rous blood, which is dark or purple or black blood, as Bichat calls 
it. This purple, or dark hue of cyanosis, is caused by the pre- 
sence of black blood only in the capillaries. But, when this dark 
hue of the cutaneous capillaries is seen, it is evidence of a similar 
hue of all the capillary blood, whether in the abdominal, the tho- 
racic, or the cephalic cavities and organs. This purple state of 
the blood is not fatal, except it exist in the brain, whose power it 
suspends. If it be chased out of the brain, by oxygeniferous 
streams of arterial blood, all the organs and tissues that lie under 
the control and dominion of the nervous system, immediately re- 
cover their power. If the brain dies, they all perish in its fall. 
If a man die, therefore, with asphyxia, he dies because he has 
black blood in the brain. 



CYANOSIS NEONATORUM. Ill 

A man may die from fainting, or lypothymia ; and in this case 
he loses life, because the action of the brain is suspendea. The 
suspension in this case, appears to me to depend upon lessened 
tension of the encephalic mass from the sudden withdrawal of a 
portion of the blood that ordinarily distends its vessels, as in sud- 
den violent hemorrhage, in certain pathemata mentis, rapid 
changes of posture, &c. &c. 

Asphyxia is lessened or suspended somatic innervation from 
privation of the oxygen-reagent. Fainting is a similar suspen- 
sion from reduced tension and pressure ; either may be fatal, but 
each requires its appropriate treatment, w^hich is different in each 
case. 

Asphyxia is not a status of the trunk or members; it is a status 
of the brain, and only of the brain. 

If the vessels of the brain be injected by the carotids and ver- 
tebrals wdth carboniferous blood, the intellectual, perceptive, 
and co-ordinating and motion-giving brains cease to do their 
office; if new^ injections fill these same vessels with oxygeniferous 
blood which chases out the former, the powers of the brain are 
reinstated, provided the mischief have not already gone too far. 

A man etherized, or affected with chloroform, is to a certain 
extent asphyxiated, besides being poisoned; the same is true of 
him, as of the well-digger, who descends into a well filled with 
carbonic acid gas. The man in the w^ell dies, not because his 
glottis is closed by spasm, but because there is no oxygen to be 
carried to the brain. It is indifferent to him whether his glottis 
be shut or open, since there is nothing to enter in that can do him 
good or harm ; he dies from w^ant of oxygen ; and it may be, that 
the carbonic acid, if it enter his lungs, may do some mischief 
there; an indifferent mischief in the greater ill. 

I said that asphyxia is black blood in the brain, not in the 
sinuses and veins of the brain, but in the capillary part of the 
vascular cyst of the brain. The greater part of the whole amount 
of the blood, w^hich is variously computed to be about thirty 
pounds, exists in the systemic part of the vascular circle. Only 
a small portion of it is in the venous side. 

In the lungs, for example, when the pulmonary artery is a vein, 
and the pulmonary veins arteries, there is a great excess of the 
aerated, over the quantity of carboniferous blood, for not only is 
the capillary system full, but the venous is full. But the carbon- 



112 CYANOSIS NEONATORUM. 

iferous blood of the femorals, and of the iliacs, of the portal, and 
the cavS, produce no asphyxia; nor is it true that in death from 
carbonic acid inspired in a well, the demise depends upon the 
presence of black blood in the trunk or members; it depends 
upon its presence in the brain, particularly the respiratory, oxy- 
genating brain, whose pneumogastric branches, and all other 
sources of respiratory innervation are suspended and cut off in- 
deed, because their neurine is flooded with carboniferous blood in 
which there is no power to extricate the biotic force — the nervous 
force. 

If it be true that there is a valve on the left side of the auricular 
septum, it must be that its purpose is to prevent regurgitation of 
the blood from left to right. 

Even in a case, when greater power of the right auricle impels 
a portion of the black blood through the valved orifice, any resist- 
ance offered by the valve must tend to diminish or prevent the 
transit from right to left. 

If in any such case the plane of the septum auricularum be 
rendered horizontal, by placing the child upon its right side, the 
blood of the left auricle must tend to close the aperture by press- 
ing the valve down, and keeping it down. The blood has gravi- 
tation, and its law of gravitation is as rigorous in the auricle, as 
it would be in a cup, or in the air. Its weight must shut the 
valve, if any valve exist. But, with a shut valve, all the blood 
of the auricle must pass to the right ventricle, and so to the lungs 
to be aerated. But, if the blood becomes truly aerated it is become 
oxygeniferous, and transferring the oxygen to the capillaries of the 
brain, will there excite the biotic force in a normal manner ; all 
the irregular and diseased innervations depending upon the ante- 
cedent carboniferous quality of the blood of the encephalic capil- 
laries must vanish before the steady innervative streams that 
proceed from a healthy brain, duly supplied with its quantum of 
oxygen. 

There are many of my medical brethren who deny that my 
explanation of cyanosis neonati is correct, or even philosophical, 
contending that cyanosis is a status of the lung, or of the vessels 
of the heart bringing about a modality of the lung alone ; while 
I aver that the condition of the lung, or of the trunk and mem- 
bers, is nothing in the category, which relates only to the state of 
the brain. 



CYANOSIS NEONATORUM. 113 

I am quite conscious that a man's opinion cannot determine 
the least of Nature's laws to operate this way or that. St. Mat- 
thew^ tells us, *^ neither shalt thou sw^ear by thy head, because thou 
canst not make one hair white or black." 

Wliile, therefore, one gentleman sees only in a contracted pulmo- 
nary artery, or in a transposition of vessels, a cause of cyanosis, I 
am not to expect that he will come over to my way of thinking, 
because I think so, even had I the authority and power of the man of 
Pergamus, who ruled us for fifteen hundred years. I am, however, 
less concerned to witness the acceptation of my rationale, than the 
adoption of my precept. If they will turn the cyanosed neona- 
tus upon its right side and shut down the auricular valve, I ought 
to be satisfied; and indeed, one distinguished author recommends 
the practice, while he dispraises the principle upon which it is 
founded. 

Nevertheless, I admit that I sincerely desire to find a rea- 
soned acceptation of my rationale ; less perhaps on account of 
its application to the undeniable self-demonstrating instances of 
blue disease, than to the treatment of certain obscure, and per- 
haps questionable forms of the accident. 

In order to explain my meaning more clearly, I shall relate a 
case that occurred to me a few years since, and upon which I put 
a construction that will not be admitted by those who oppose my 
rationale of cyanosis, either as to its mechanism or its real nature, 

A lady had given bjrth to a child, apparently healthy. She 
was soon afterwards attacked with fever, which produced in her 
a series of distressing nervous symptoms. The young child, after 
many days, became indisposed with what seemed to be a bron- 
chial catarrh, which was rebellious under the treatment. Dr, 
Bridges saw the child with me several times. It grew alarmingly 
ill. It was affected with a vast, troublesome collection of unex- 
pectorated bronchial mucus, that threatened speedy suffocation by 
filling the air-tubes and trachea. Upon entering the apartment 
on one occasion, I found it in the arms of the monthly nurse, 
sorely oppressed and nearly insensible. It was dying; or rather I 
deemed it dying. 

My impression from inspecting the child was, that it was mori- 
bund, and I still believe that the condition was that of the mori- 
bund, and that its life could not have been protracted beyond 
one or two hours, but for remedies employed to rescue it. 
8 



114 CYANOSIS NEONATORUM. 

After observing it for some time, and noticing a livid areola 
about its mouth, I took it from the nurse to inspect it more 
closely. 

The precise processes of thought by which I arrived at a con- 
clusive opinion, have now escaped me; but I was led to imagine 
that the whole of the phenomena ought to be referred to a state of 
the brain, and not a state of the bronchial mucous membrane. I 
supposed that the sources of innervation becoming modified by the 
presence of carboniferous blood in the brain capillaries, the organs 
had suffered in consequence of the cessation, or irregularity, of 
the administrative power. Upon cutting, in a surgical operation, 
certain branches of the trifacial nerve, the eye becomes instantly 
inflamed. Dr. J. Warren says, that under etherization, the con- 
junctiva is often injected with blood. So, in any hinderance of 
the current of the pneumogastric nerve-force, the lung might also 
become the seat of consecutive disorder. I was convinced that 
the child's foramen ovale admitted its venous blood to the sys- 
temic side of the circle, thus vitiating the biotic power of the 
nervous mass of the child. I turned it on its right side, and kept 
it there. In a few moments it was relieved, and in a very short 
time gave no further reason for alarm, or concern of mind. In 
fact, the right lateral decubitus cured it. 

In the month of January, 1846, I attended Mrs. Hoobly at the 
Indian Queen, South Fourth Street, in a confinement in which 
she gave birth to a healthy child. 

As she was ill many days with a fever, I gave but little atten- 
tion to the child. It vras between two and three weeks old, when 
I was summoned to it by three rapidly repeated messages. I 
found it insensible ; affected at intervals of one to two minutes 
with convulsions, in which the head rotated to the right in strong 
extension; the right arm, stiffened, was elevated as strongly as 
possible by spasmodic innervation of the deltoid, while the left 
arm also stiffened, was pointed downward and outwards. The 
inferior extremities were also affected with rigid spasm. The 
mouth was open, and could not be closed, but by force. The 
pulse was feeble, and the respiration low, except when troubled 
by the recurring spasm. Many persons surrounded the infant, 
which was on its back on a pillow, supported on the lap. 

The child had been well but a short time before. The attack 
had been a sudden one. 



CYANOSIS NEONATORUM. 115 

Upon contemplating the child, which had two or three attacks 
of this spasm, or convulsion while I was looking on it, I rea- 
soned with myself as to the probable cause. There w^as no 
assignable hygienic causation. 

Its mouth was bluish, though not in a very marked degree. 

I took the child on its pillow, and laid it on my knees, in order 
the better to inspect it. I said, here is a faulty innervation of the 
muscles of the head, neck, arms, legs, and lower jaw. Are the 
parts in fault, or is the brain in fault? whence these irregular 
intromissions of nerve-force ? Is the nervous mass imperfectly 
oxygenated because the child sends its carboniferous blood into 
the left auricle, and so to the brain? 

I laid it on its right side in the cradle, its trunk elevated at 
about 15°, and I said, leave it in this position until I return. Per- 
haps it will die very soon ; but I have some reason to hope it may 
be saved, if you should not change its position. I shall be ab- 
sent three hours. Do not venture to move it, until I come again. 
In the meantime while I remained, it changed its appearance 
speedily and visibly for the better; it had no return of the spasm. 
It fell into a calm sleep, and was perfectly well when it awoke. 
It required no further care. 

Was this a post hoc, and not a propter hoc case? Who can say 
so? The treatment was reasoned beforehand, and the result 
looked for. 

As well might it be said that every therapeutical cure by eme- 
tics, cathartics, or narcotics, or diuretics, is a post hoc, and not a 
propter hoc cure. 

The blood in the auricle or ventricle, is not exempt from the 
laws of matter ; it gravitates as absolutely there as in a teacup, 
or in the air. When I lay a child upon its right side, gravitation 
of the blood is inevitable; and since the valve is as delicate as 
the arachnoid, the smallest drop resting upon it could close, as the 
slightest force could open it. 

I brought the plane of the septum auricularum, to be a hori- 
zontal plane ; I compelled the blood of the inferior cava to rise 
in a vertical current to the fossa ovalis, and thus lessened the 
power of Eustachi's valve, to direct it upon the fossa ovalis. I 
shut the valve down by the weight of the superincumbent blood, 
and all the blood of the right auricle passed through the iter ad 
ventriculum, in order to be breathed upon in the lungs. It is 



116 CYANOSIS NEONATORUM. 

probable that half a dozen systoles of the heart had scarcely been 
effected, before the oxygeniferous streams had reached the neu- 
rine, and waking into orderly and healthful force, the before hebe- 
tized innervations of the child, all the dependent organisms and 
organs resumed their healthful movements and manifestations. 

Nov. 20, 1847, 1 was called to the child of Mr. H , in Pine 

Street below Eighth. This child, a female, was born in October, 
1847, and was now six weeks old. Upon reaching the rendez- 
vous, I was pained to find the infant dangerously ill with catarrho- 
pneumonia so far advanced, that T informed its mother it was pro- 
bably too late to do it any great service. 

The bronchial tubes and the trachea were oppressed with a great 
quantity of mucus, which so obstructed the respiration, that the 
child coughed at every breath, which was very short, saccadee, 
and repeated sixty or seventy times per minute. Percussion and 
auscultation of the chest — careful examination of the abdomen — 
inquiries into the rate of the pulsations, both by feeling the ra- 
dial pulse, and by auscultation of the heart, led me to the pain- 
ful expectation that my friends were about to suffer the loss of 
their daughter. I prescribed for it, under the diagnosis of a 
catarrho-pneumonia. Some hours afterwards I repeated my visit. 
It was no better. 

Upon taking the child, which was on a pillow, and resting 
it on my knees, I found it in danger of suffocation. Every 
breath was a compound of coughing and crying, which I can- 
not describe, but which every physician has observed. Upon 
inspecting it, I observed a livid areola of the mouth. The feet 
were bluish, as well as the finger-nails. It is true that such 
blueness might depend, and did in part depend, on the sabur- 
ral state of the pulmonary mucous membrane— smeared as it 
was with mucus, and the tubes partly filled up. As the attack 
had been sudden — too sudden to be conformable to the normal 
march of such maladies, I reflected that the fault might not be 
primary in the respiratory mucous membrane, or pulmonary tex- 
ture, but in the brain, which had lost its power of maintaining the 
status sanitatis in the lungs. I deposited the infant on its side, as 
for the treatment of cyanosis neonati. It seems to me that the 
valve of Botalli fell down upon the foramen ovale, and that the 
carotid and vertebral injections of the brain immediately began to 
be thoroughly oxygeniferous. The administrative nervous mass 



CYANOSIS NEONATORUM. 117 

commenced anew its government of its provinces, and, in a short 
time, the symptoms of the disease had vanished; I found in the 
morning of Nov. 21st, that no further treatment was necessary. I 
cured the broncho-pneumonia by shutting Botalli's valve, just as 
I should cure a conjunctivitis, by restoring the integrity of the 
trifacial branch cut off in a surgical operation on the face, and the 
loss of whose innervative current might have determined the con- 
junctival inflammation. 

The objectors do not deny that the foetal circulation, up to the 
first act of respiration, is through the foramen ovale, and the arte- 
rious duct, and that it is so indispensably, and only because the 
operculum is raised. They cannot deny that the aperture virtu- 
ally exists after birth, even for many days — nay, in some, during 
a long lifetime. 

To deny that the two zygo-zoar halves of the heart may act 
asymmetrically and asynchronously, is to deny an admitted truth. 
To deny the effect of such dissidence in time and force, appears 
to me to be but a mere denial. 

I had many years ago charge of the health of a young woman, 
who labored under frequent attacks of cyanosis. She was often 
threatened with sudden death. In the intervals she appeared to 
be in good health, earning her bread by the needle. 

One day while much indisposed, she sat up in bed eating a 
dinner of codfish. She suddenly fell on her side dead, in her 
28th year. I found a foramen ovale, into which I could put a 
swan- quill. 

In the heart of the Archduke Joseph, the cyanosis had coin- 
cided all his life long with an open foramen ovale. — See GintraCy 
p. 228. 

If in my own heart there be an aperture as large as the end of 
my finger, it is indifferent to me in respect of my health, while 
the two auricles contract symmetrically. But if asymmetrically, 
then I am liable to sudden illness, or even sudden death. My 
patient probably flooded her medulla oblongata with carbonife- 
rous blood, and ceased to breathe in consequence of the annihila- 
tion of biotic force evolved from the medulla. 

How often have we seen similar states of the system brought 
about in attacks of puerperal eclampsia? 

In this disease, an impetuous sanguine circulation gives rise to 
unmeasured, I had almost said, explosive evolutions of biotic 



118 CYANOSIS NEONATORUM. 

force. In eclampsia, the spasm and convulsion of the whole sys- 
tem, and particularly of the diaphragm, which often makes aspi- 
rations of only three or four cubic inches of air, allow the carbon- 
iferous streams to overflow the encephalon. Under this want of 
aeration, the face gathers blackness apace — the protruded tongue 
is of a deep purple, and a true asphyxia intervenes between the 
life and the death of the patient; so that the sooner the blackness 
of the features and tongue comes to assure us of the arrest of the 
cerebral excitation, the sooner is the patient to be extricated from 
her perilous predicament. 

If the medulla oblongata be overwhelmed, she dies ; sometimes 
this is the case, and she dies outright, no trace of lesion being 
discoverable in the brain. 

Here we have no good and reliable resources of medication, save 
those that serve most rapidly and powerfully to diminish the mo- 
mentum of the sanguine circulation in the encephalon, of which 
venesection is to be before all others preferred. 

A proper venesection, executed before the asphyxia is estab- 
lished, in general prevents that consummation by substituting a 
state of deliquium for the otherwise inevitable asphyxia of the 
eclampsic paroxysm, a far less dangerous and more speedy way 
of escape. Less dangerous, since the sanguine engorgements and 
retardations coincident with the cyanosed state of the brain in 
eclampsia, expose the sufferer to inconvenient effusions or extra- 
vasation. 

As to the right lateral decubitus for the new-born child in cya- 
nosis, no doubt rests on my mind, after multiplied experience 
since 1832, now sixteen years. I am not embarrassed by^finding 
the treatment sometimes unsuccessful, because, when it is so, I 
can wdth confidence believe that failure to change in blood is 
effected through some other agency than that of an open and used 
foramen ovale. 

In the son of Mr. A. B , I detected the existence of cya- 
nosis neonati, and relieved the child, but could not cure it by my 
method. A series of diseased innervations bringing the w^hole 
constitution into ill-health, continued to manifest themselves, 
notwithstanding all the precautions I could devise, and I an- 
nounced, long before the death of the infant, which lived for 
several months, in addition to a patent foramen ovale, the exist- 



CYANOSIS NEONATORUM. 119 

ence of an aperture in the septum ventriculorum, which was veri- 
fied by the examination of its heart after its decease. 

In a similar manner I announced in Mr. J. B 's child, an 

open foramen ovale, as the cause of convulsive attacks which led 
at last to an effusion within the encephalon with separation of the 
sutures, and evident fluctuation, which was verified necroscopi- 
cally. 

Professor Wood will bear me witness of the sudden and marked 
and indubitable relief and cure of Mr. H. W 's infant, appa- 
rently dying with cyanosis, when it was placed in position. 

In the eldest son of Mr. S. B , jun., the respirations 

were but four to the minute ; the pulse was gone, and the child 
within two or three minutes of its death, nay, deemed by some 
to have breathed its last. The recovery was almost instant. 

The same is true of Mr. H. K 's son, with the exception 

that the case was not so extreme ; so also of Mr. Rich's child, 
Mr. J. W 's, and many others. 

I beg leave to refer again to the letter from Prof. Eve, at p. 98, 
reciting a case of cyanosis treated by him. A letter from Dr. 
Casey, of Hartford, Conn., informs me of a violent case success- 
fully treated by the position. Dr. Hains of this city, and many 
others, have succeeded in like manner. 

I can by no means adopt the views as to the essential nature 
of the malady, set forth in Prof. Wood's late work on the Prac- 
tice of Physic. That author, like others, appears to me to have 
mistaken the symptom, to wit, the blue color for the disease, which, 
as I have so often said, is essentially a failure of innervation from 
absence of oxygen in the brain. He doubts the causation as 
dependent on the mixture of the two kinds of blood in the heart. 

I cannot understand that the leg or arm should suddenly die for 
want of oxygeniferous blood ; and I cannot perceive how the consti- 
tution can live, if the nervous mass, which is the essential Ens, be 
dead, or inert, as it certainly is when only the decarbonized blood 
of the veins circulates in its capillary vessels. M. Gintrac him- 
self, who originally made four kinds or species of cyanosis — of 
which the first consists of the melange du sang noir, et du sang 
rouge, and the second a coloration hleue egalement constituee par 
ce melanges-comes to the true conclusion at last, that, instead of 
four species, there is but one, although he calls that one two. 

I deny not that a constriction of the pulmonary artery may pro- 



120 RESPIRATORY DISORDERS. 

duce cyanosis. "Whatever restricts the action of the venous heart, 
must do so. Great collections of fluid in the thorax produce it. 
Pressure upon the heart from dropsy of the pericardium ; extensive 
injuries of the lungs from tubercular degeneration; suppurations, 
and large vomicae ; cynanche trachealis, or pseudo-membranous 
laryngiHs; pneumothorax; atelectasis pidmonum ; a host, indeed, 
of accidents and diseases that ruin or disable the respiratory 
machinery, may produce cyanosis. But of these I have not 
spoken. I confine my proposition to the persistent use of the 
foramen ovale after birth, a use in which the blood of the veins 
takes the course originally followed by that of the placenta. 

There is no other treatment for cyanosis neonati than that I 
have suggested ; at least, there is no other reasonable treatment. 
Venesection, emetics, purgatives, diuretics, soporifics, baths, 
counter-irritants, cannot cure it. 

When cyanosis has introduced epiphenomenal affections, they 
maybe treated. These affections will be found to relate chiefly to 
a state of the pulmonary circulation and excretions. 

In some instances I have applied a large leech or two to the 
region of the heart, in order haply, to assist in overcoming the 
pulmonary or cardiac engorgement, so apt to coincide with fail- 
ure or disorder of the biotic power of the medulla oblongata. In 
general, however, when the malady has depended on the injection 
through Botalli's foramen, I have been content to place the infant 
in the proper position, and trust to that alone for the cure» 



CHAPTER IX» 

RESPIRATORY DISORDERS. 

The disorders of the respiration are among the most fatal of 
those that attack young children. 

Independently of the primary affections of the respiratory or- 
gans, there are many examples to be met with, in which other 
maladies^ having originally no direct relation to a condition of the 



RESPIRATORY DISORDERS. 121 

aerating apparatus, come at length to trouble the course of its 
functions, and cut short an existence, which but for such in- 
tervention might have been readily secured against the tenden- 
cies of the principal attack. In scarlet fever, for example, a 
major part of the fatalities are referable, not to the lesions of tis- 
sues, or the exhaustion of nervous force from intense irritation — 
but to the obturating and occluding effects of swellings, and viscous 
secretions and plastic exudations on the air passages, which, 
agreeably to my clinical experience, are the causes of death in by 
far the greater proportion of those who succumb after the first 
three days of scarlatina. 

There is little occasion for surprise at the dangerous nature of 
the maladies that contravene the respiratory office, since what- 
ever hinders, by diminishing or preventing, the due oxygenation 
of the tissues, and especially of the nervous mass, constitutes a 
direct attack upon the very principle of existence. 

Having already, in my observations upon cyanosis neonatij, 
spoken at some length on the subject of the respiration, 1 might 
perhaps avoid the accusation of ''iteration'''^ by going at once to the 
task of describing the phenomena of the respiratory disorders, and 
pointing out the course of the treatment that I deem most appro- 
priate for each individual form or variety of such affections. 

But there is little need for renewed description. Descriptions 
the most accurate and elaborate abound in the medical library, 
and I should not now take the trouble to write with the sole and 
superfluous view of painting the visible and cognoscible pheno- 
mena of diseases familiarly known. It is better not to write, than 
to write merely in repetition of what authors, better qualified, have 
already done in this line. And it is only in the hope of present- 
ing certain views of some of the pathogenic and pathological 
principles that ought to lie at the very foundation of our thera- 
peutical intentions, that I shall indulge my inclination to speak^ 
perhaps iteratively, upon the subject of the disorders of respiration. 

The importance of this function is so great, and its perform- 
ance so indispensable, that there is no living creature unendowed 
with some means of effecting it. The lowest medusa or holothu- 
ria has its air-sac. The tiniest insect has its trachea ; the fishes 
have branchiae or gills ; and the reptiles, birds, and vertebrates 
are provided with lungs, by means of which to aerate their juices^ 
their solid substance, and their blood. 



122 RESPIRATORY DISORDERS. 

The quantity of air consumed in the aerating process has 
some relation, or bears some ratio, to the intensity of the life of 
the subject. It is impossible that life can exist or be made 
manifest in full perfection, where let or hinderance is interposed 
betwixt the body and the oxygen that aerates it and the fluids 
of it. 

There is no other access of oxygen to the interior of the body, 
tlian that through the blood in the lungs — for, it is useless to 
impute as such the oxygen ingested in drinks or in food. 

The oxygen is admitted by the nostrils. The mouth also 
sometimes admits the atmospheric air in persons who from any 
cause fail to breathe by the natural respiratory apertures, the nos- 
trils; for of men it has been said truly, "whose breath is in their 
nostrils.'' The access may be restrained, or cut oflf by diseases 
of the mouth and nostrils. 

The breath passes into the lungs by the larynx, trachea, and 
bronchi; whatever comes to obstruct or close these passages, 
hinders or prevents the access of air to the lungs. 

The bronchi terminate in what are called air-cells, which are 
the termini of the bronchi. — They constitute the essential respira- 
tory organs ; but they are accompanied by capillary branches of 
the pulmonary artery, or capillary radicles of the pulmonary 
veins — as well as by similar branches and radicles of the bran- 
chial artery and vein. They are also enveloped in nerve fila- 
ments ; and their absorptions take place by lymphatic absorbents. 
All these materials are encompassed and enveloped in a gangue of 
cellular tela. It is evident, therefore, that diseased action in the 
pulmonary artery or vein extending to the capillary system of these 
vessels., or similar states of the branchial vessels, or of the nerves, 
©r absorbents, or cellular tissue of the lungs, may, to a certain 
extent, interfere with, or wholly prevent, the due exercise of the 
function of the lung. For example, if the pulmonary artery should 
yield to the lateral pressure of the blood, and if the capillary 
branches of that artery should also yield, and allow too great a 
quantity of blood to reach the lungs, rendering it in this sense 
plethoric, hr hyperaemic, we shall find some derangement of the 
health as a consequence. 

The same may be said as to the branchial artery. If, too, the 
recrementitial absorbing apparatus loses its power, we shall find 
the results of that failure in the state of the respiration ; and if 
ike nerves do not transmit the nerve-force in due intensity, neither 



RESPIRATORY DISORDERS. 123 

too much nor too little, disease becomes evident. Lastly, if the 
halitus of the tela-cellulosa be not withdrawn, but be allowed to 
accumulate, we shall have oedema pulmonum, with all the epi- 
phenomena arising from the presence, and pressure of serum, in 
the cellular membrane. 

Again, the blood is a variable element of the body. Its crasis 
is ever changing with the ingestion and digestion of food, with 
the progress of the secretions, and excretions, and exhalations; 
with exercise and rest, with hunger and thirst ; and with satiety. 

The crasis of the blood is not the same in any two consecutive 
moments, and the modifications of the crasis so far as dependent 
upon the aqueous proportion of it, are to be held as modifying its 
power to undergo the process called aeration. That is to say, a 
thin, watery or anaemical state of the fluid admits of a lesser pro 
rata aeration of it than a rich, valid or plethoric condition. 

Further, the blood is modified not only by the augmentation or 
diminution of its aqueous portions, but also by the quality and 
nature of its solid parts. The discs are less perfect or the fibrin 
and albumen more or less abundant in a ratio to the quantity of 
the discs in some than in other specimens. 

It is clear that modifications of the condition of the blood may 
and do exert a pathogenical influence, as either laying the founda- 
tion of disease in the organs and organism, or as promoting and 
favoring diseased action already begun or established by other 
causes or elsewhere. 

Finally, the source of all vital power is in the nervous mass — 
whether the cord or its bulbs, the great sympathetic or the 
plexuses, or the nervous tractus, wherever situated. But if the 
source of power fail, the organs that are sustained, and that are 
vitalized by means of its irradiation, will fail likewise. Hence 
many diseases are the direct results of failure in the nervous mass, 
at the sources of irradiation, or of the nervous tractus rendered 
incapable of transmitting the power. Thus passions of the mind 
may determine the attacks of asthma. Irritations of the stomach 
from prava ingesta may in like manner irritate the brain to pain, 
or delirium, to asthmatic paroxysms, or spasmodic laryngitis, or 
laryngismus. The division of a nerve in the face may be instantly 
followed by conjunctivitis. The pressure of the emerging cusps 
of a molar tooth may excite the cerebellum, and end in the most 
explosive extrication of nervous force, manifested by epileptiform 



124 RESPIRATORY DISORDERS. 

convulsion in the teething infant. It is needless to cite examples 
which are innumerable. 

In any case of respiratory disease affecting a young child, 
the physician will find himself dependent upon his own powers 
of discrimination as to the diagnosis, since the sufferer cannot 
make any verbal relation of the seat, cause, kind, or degree of 
his sufferings. The elements of our opinion exist in the rate 
and effects of the respiratory office. Its rate consists in the 
number of its aspirations taken in a given time ; in their complete- 
ness or incompleteness ; in their facility or difficulty ; in their 
apparent ease or painfulness ; in the employment in them of the 
accessory muscles or not ; in the heat of the body, resulting from 
them ; in the color or tint of the general surface, and of the visi- 
ble mucous surfaces ; in the sounds that accompany them, whether 
heard at a distance or by auscultation, and in percussion. Much 
useful and most precise information may be acquired, by attend- 
ing to the decubitus and gestures of the child; to its cries, 
its cough, its physiognomical expression, its cutaneous transpi- 
ration; and to its power of ingestion, as well as its appetite. 

It is not necessary merely to breathe ; there must be just so 
much breathing, neither more nor less. The body must be oxygen- 
ized. If too highly, there is evolved an excitation to be charac- 
terized as plus ; if insufficiently, the excitation will be characterized 
as minus; neither of these is consistent with real health or com- 
placency, or agreeable sensations. 

In the machinery of the respiration, the thorax or the body 
may be compared to the cylinder, and the diaphragm to the pis- 
ton of an engine, which works at full, or half, or quarter strokes ; 
and which makes a greater or less number of revolutions in a 
given time. 

I have seen the diaphragm contracting more than 200 times a 
minute in an hysterical female, for considerable time together. 
The reader has his own diaphragm so far under the control of his 
will as to be able voluntarily to make it contract at such rate, 
for a short time together ; but even a very short experiment suf- 
fices to convince him it cannot be done without exposing him to 
pectoral, or pulmonic, as well as encephalic sensations, that are 
anything but agreeable, and the continuance of which but for a 
short time, would be found by no means safe. 

There are various estimates of the quantity of air inhaled at 



RESPIRATORY DISORDERS. 125 

each ordinary aspiration. It is unnecessary to be exact in the 
proportions. If it be computed that a man of ordinary size breathes 
18 times per minute, and aspires 18 cubic inches of air, at each 
breathing, he will use 466,560 cubic inches of air per day, or 
324 per mainute. 

Four hundred and sixty-six thousand five hundred and sixty 
inches, are what he requires to oxygenate his nervous mass and 
his whole system, whether of fluid or solid elements, during 
twenty-four hours. To what a condition of evil health is he 
reduced, who instead of this amount, can appropriate only three- 
fourths, or one-half of the required quantity ! What efforts doth 
he make to effect the acquisition by redoubling or quadrupling the 
number of respirations, calling to his aid all the voluntary acces- 
sory muscles of aspiration, and exhausting the nervous mass by 
unintermitted drafts upon it for the biotic force with which it alone 
can innervate the respiratory engine and machinery! The con- 
sumption of nervous force is here rapid and exhausting to the last 
degree; and the direst spectacles of human woe are to be ob- 
served in certain persons affected with dyspnoea from hydrothorax, 
or croup, or other suffocative disorders. 

I repeat, to what a condition is man reduced whenever a small 
per-centage of the oxygen is withheld! Even a small portion 
being cut off distresses, a large portion procures for him agonizing 
sensations of suffocation, and when a still larger suppression 
occurs, it delivers him over to an inevitable death. 

It could not be otherwise if the doctrine be true; that the con- 
tact and mutual reaction of oxygen and the nervous mass is the 
antecedent or cause of the biotic force, or innervative force. 
Respiratory disorders that diminish or hinder this essential reac- 
tion, are assaults upon the very founts of animal life,»and the hin- 
derance is not only to the organ that is the seat of the disorder, 
obstruction, or inability, but it tends to overthrow directly all the 
other functions of organs, by depriving them directly of a part 
of their requisite supplies of nervous force from the fountain head 
in the cord or its bulbs, or in the great sympathetic system. 

Inasmuch as I have in a former part of this volume, (p. 58,) 
expressed the opinion, that certain young children do perish from 
a respiratory want occasioned by coryza, or other obstruction of 
the nasal passages, I shall not recur here to a consideration of 
that accident. 



126 CROUP. 

It is said that persons occasionally perish from mere spasm 
of the larynx. 

The word croup, in its most general acceptation, is expressive 
of a supposed spasm of the larynx, wherefore it is called spasmo- 
dic laryngitis, and from the peculiar sound of the voice, stridulous 
laryngitis, Millar's andWichmann's asthma. In this case, it has 
been observed that spasm, affecting a muscle of the glottis, the 
arytenoideus transversus, may close the aperture, and cut off the 
access of air to the respiratory surfaces in the air-cells, the oxy- 
genating surfaces. But a state of inflammation of the larynx is 
asserted in the very term laryngitis, to accompany this spasm, for 
the termination of the word in itis is employed to express the idea 
of inflammation. Perhaps it may be strictly true that, even in 
the simplest forms of the affection, called spasmodic croup, there 
exists a degree of inflammation of some portion of the laryngeal 
structures, which serves to modify the action of the glottis in the 
respiration. In a perfectly healthy individual, the glottis always 
gapes in the act of aspiration, as shown by Dr. Wilson Philip in 
his experiments upon rabbits at pages 32, 33, in which he shows 
also that the motions of the glottis depend upon the eighth pair, 
whose section always puts an end to its motions. It is not to be 
doubted then, that while the glottis must be very liable to spasm, 
under whatever states of irritation, it is also liable to a paralytic, 
or hyponeuric condition in other states of the nerve power, 
whether as depending upon changes in the vagus, or in the parts 
of the brain from whence the vagus derives its origin ; and 
whether as aflecting the muscular, the mucous, or the cellular 
textures that enter into the composition of this organ. 

It is quite true that in spasmodic croup, or spasmodic laryngitis, 
it often happens that although the patient may have been very 
suddenly attacked, and almost as suddenly relieved, he is not- 
withstanding left, for some time after the relief, affected with signs 
of an altered condition of the windpipe; that is to say, he will 
be a little hoarse ; and upon any attempts at rapid, or sudden 
aspiration, he will find that the croup sound is still there ; as is 
the case also in the act of coughing, and this, though in any 
ordinary rate of breathing, not the least sign of difficulty can be 
perceived. 

This seems to me to show, that what is called spasmodic 
croup, is not merely spasm, but that there is a substratum of 



CROUP. 127 

congestive or inflammatory disorder, which ought not to be lost 
sight of by the medical attendant. To look upon it as merely 
spasmodic, and thus wholly contradistinguished from the graver 
forms called pseudomembranous laryngitis, is to make a serious 
mistake, as diminishing the apprehension of danger, which in fact, 
is not gone as soon as the spasm of the larynx has been removed 
by the therapeutic influence of a nauseant, an emetic, or both. 

Experience, indeed, shows that an attack of the malady that 
makes its first appearance, say at 11 P. M. during the first sleep,, 
and which is apparently vanquished by a dose of ipecac, is very- 
likely to be repeated on the following night. My opportunities for 
observation have deeply impressed upon me the opinion that, in 
a majority of attacks, there is a recurrence of the phenomena^ 
some time in the next succeeding night, which I deem confirma- 
tory of the notion, that there is always in these cases a real in- 
flammatory condition of the parts of the windpipe. It appears 
to me highly improbable that we should so commonly witness this 
occurrence, were the malady eclampsic or nervous merely. 

The public in general are well aware of the dangerous nature 
of the affections of the windpipe ; and an attack of croup is 
therefore sure to rouse the apprehensions of parents, who make^ 
however, no distinction of diseases, all suffocative affections of the 
larynx being included together under that dreaded name. 

In this confounding together of two very different maladies, 
the public commit a great error, since the diseases have different 
courses, intensity, and tendencies. 

In sample spasmodic laryngitis, or ordinary croup, there is often 
not the least reason to suppose the child sick until the moment of 
explosion of the attack; an attack which in many examples is 
more violent in the first moment of its existence than in any sub- 
sequent time. In these instances, a child is put to bed under 
usual circumstances, falls asleep, sleeps tranquilly for an hour or 
more, and then in an instant, in a manner truly eclampsic, it starts 
from its repose in the most violent agitation and fright, suffocated, 
coughing, and giving out the peculiar laryngeal sound called 
Grouping, and causing the attendants to fear an immediate suflfo- 
cation, so difficult and laborious is the respiration. The face 
becomes excessively flushed ; the head, neck and hands are be- 
dewed with a sweat of agony; the pulse becomes hurried, and 
in a short time the heat of the body is considerably augmented. 



128 CROUP. 

Amidst cries, and fits of coughing, and choking, the patient 
gradually becomes appeased; and when the diaphragm recom- 
mences its gentle and normal acts of aspiration, the air is found 
to pass into the trachea arteria with very little, or perhaps with 
no sound. But upon any renewal of the coughing, or of the 
cries, the spasm of the larynx is set again on foot, and the patient 
must pass through another paroxysm. A very similar state of 
things is to be observed in the paroxysms of an ordinary pertussis. 

In all these phenomena, I can discover naught else than ajBTec- 
tions of the laryngeal branches of the pneumogastric nerve, whose 
sensitive cords being brought under a maladive influence, it calls 
into sympathetic disease the motor or spinal accessory cord, that 
must be supposed to run pari passu with the former. 

I have often noticed a condition in w'hich an action the inverse 
of this takes place. I allude to the effects of violent exercise 
upon the throat, in boys after a long race. For example, I have 
seen boys who have determined to run a mile, obliged to stop by 
the coming on of a spasmodic stricture of the larynx, which not 
only admonished them that the effort had already gone too far, but 
compelled them to stop the career; the larynx perhaps refusing 
any longer to gape, at each aspiration, because the motor branches 
of the eighth pair presiding over that office had become exhaust- 
ed of innervative force. The runner, upon sitting down, in 
general finds that the suffocative sensation soon disappears; yet 
it ordinarily happens that a decided hoarseness follows the effort 
and continues for many hours. In this case, the motor cords, or 
spinal accessory, being exhausted, the sensitive or pneumogastric 
cords are sympathetically distressed, and allow of the engorge- 
ment, inflammation or submucous infiltration that would consti- 
tute the pathological condition introduced by the race. 

The same thing occurs to the public speaker. A public dis- 
course, lecture or harangue, may go on for an hour without mo- 
difying the two vocal powers of the larynx, whose moving parts 
are normally actuated by the will transmitted through the spinal 
accessory branches. But, as soon as the exercise is over, it is 
found that the sensitive cords have allowed the texture to assume 
that state which produces hoarseness, and a feeling of soreness or 
sensibility of the throat ; and in many persons, the frequent repe- 
tition of these acts lays the foundation of what is called preachers' 
cough, or parson's cough. 



CROUP. 129 

These views lead us to inquire, whether or no the cases of spas- 
modic croup are not sometimes purely nervous affections, or disor- 
ders arising from modifications of the state of the respiratory brain, 
and acting upon the windpipe — and not affections of the windpipe 
disturbing the action of the respiratory brain. 

I have already very fully expressed my belief as to the predo- 
minance of qualitative states of the nervous mass, in developing 
and maintaining the forms of diseased action, and little doubt 
rests upon my mind, as to the primary and predominant qualita- 
tiveness of the nervous mass in the croupal diseases, denominated 
thymous-asthma, Kopp's asthma, laryngismus, laryngismus stri- 
dulosus, &c. &c. 

In the ordinary cases of sudden croup, or common croup, the 
agitation of the muscular system, and of the respiratory muscles 
at the onset, amounts virtually to spasm. In Kopp's asthma or 
laryngismus, real spasm not unfrequently attends, nay, it comes 
synchronously with, the laryngeous attack. 

I have witnessed, however, very numerous specimens of quite 
young children affected with laryngismus or croupal respiration, 
occurring occasionally, and being repeated daily and even many 
times a day for months in succession, in w^hom no other sign of 
the least disorder could be discovered, and which finally ceased 
to appear. In such cases, the children have grown and prospered, 
as w^ell as if not the least suspicion of doubtful health had arisen 
concerning them. 

As I have made these observations many times, during a great 
many years, I cannot doubt that the experienced reader of these 
pages will recall similar instances to his own memory, and that 
he will perceive the class of cases to w^hich I here refer. 

In such cases I have not interfered, save to observe them care- 
fully, and to use precautions of a hygienical sort. I have had 
the opportunity to observe a good many cases of true laryngismus 
stridulosus, some of them fatal ones; but I have seen by far a greater 
number of samples, in which infants, especially in the month, 
had merely the laryngismus or crowing sound, which, as above 
stated, has at length wholly disappeared, leaving no maladive traces 
behind. 

The malady called holding the breath, so often observed in 
young children, is a case of this kind produced psychologically. 
The spirit or temper of a man is often as capable of becoming 
9 



130 CROUP. 

pathogenic, as his solids, or his fluids. Holding the breath is 
one of the samples of these psychological diseases. But, to return. 

I regard laryngeal spasm as essentially connected with some, to 
me unknown, pathological condition of the medulla oblongata. 
When the malady has proceeded to the extent of bringing on con- 
vulsions, I have presumed an extension of the pathological state 
from the medulla to the cerebellum, a case in w^hich the greatest 
danger menaces the life of the child. Some of those who have 
perished, have succumbed to fatal extensions of the pathological 
lesions to the cerebrum, marked by symptoms of real hydrence- 
phalus, while others have died instantly, as if by a sudden sup- 
pression of the forces appertaining to the respiratory bulb of the 
brain. 

The true croup, or plastic croup, pseudomembranous laryngitis, 
a form in w^hich plastic exudation from the mucous membrane 
comes to choke and fill up the canal of the windpipe, is, per- 
haps, the most dangerous form of the maladies that w^ere formerly 
grouped under the name of croup. I regard it as more dangerous 
than laryngismus stridulosus, or Kopp's asthma — for the reasons 
above set forth. But I desire not to be understood as expressing 
the opinion that it is more dangerous than Kopp's asthma, when 
that is attended with convulsion, for, in such extreme violence of 
the disorder, the cerebellum, and sometimes the hemispheres, are 
greatly involved in disease. 

True croup does not in general attack suddenly. It is ushered 
in by hoarseness and wdth slight cough ; there is some feverish- 
ness — and a depression of the spirits which is very marked. The 
muffled tone of the voice goes so far as to become a whisper — so 
that even in slight attempts to cough, and in crying, the sounds 
uttered are w^hispered sounds. 

This state of things may be observed for one or more days, 
until at length, in a fit of crying or coughing, the peculiar croup- 
ing is heard undeniably. 

As a general rule, it will be found that the posterior parts of 
the palate, the arches and the tonsils are now flecked with clots or 
patches of lymph-exudation, which, it is to be presumed, also ex- 
tend into the glottis and whole canal of the larynx — descending 
along the aspera arteria into the bronchi. Such diphtheritic in- 
flammation, if not arrested, tends to fill the tube w^ith exudation 
corpuscles, which, adhering to the superficies producing them, at 



CROUP. 131 

length fill up the tube so completely as to cut off the access of air 
to the respiratory cells. As soon as the obstruction has reached 
such a grade as to prevent a supply of oxygen sufficient to carry 
on life with due vigor, the patient begins to succumb — to sink — 
and at length to die. 

I have now enumerated the different forms of laryngeal dis- 
ease, that have formerly been interchangeably called croup — vi- 
de!, spasmodic laryngitis — laryngismus strididosus, and pseudo- 
membranous laryngitis — of which the latter alone is deserving to 
be called true inflammation of the organ — though in the first named 
case there is reason to suspect the presence of engorgement at 
least, and also, perhaps, a slight inflammation of the mucous 
membrane, as I remarked in a former page. 

I have met with one case, in a child about two years old, in 
which violent respiratory distress was observed, upon every at- 
tempt to sw^allow. There w'as no tonsillitis, but I discovered that 
the posterior w^all of the pharynx was thrust forwards, and sup- 
posing it to be lifted by a purulent collection behind the mucous 
membrane, I punctured it, and let out a considerable quantity of 
pus, w^hereupon the child was relieved. 

Two samples of a similar purulent deposit behind the pharynx, 
have, within my knowledge, proved fatal to adults by occluding 
the glottis. 

The case is doubtless a rare one, — which moves me to record 
it here. In all those samples of inexplicable difficulty of breath- 
ing we meet with, it is w^ell to remember that they may possibly 
arise from such disorder of the pharynx. 

In the spasmodic croup, whose assault and ordinary progress I 
have already described, I have rarely found it necessary to resort 
to venesection in the treatment. 

When a child has suddenly started from its repose in the man- 
ner described, it is usual to get the feet as soon as possible into 
a warm bath, which should be rendered warmer by the frequent 
addition of portions of hot water — so that the pediluvium may be 
continued until the heat of the bath becomes nearly intolerable. 
I think that the temperature at first should be about 92° or 94°, 
and that the bath should last about ten or twelve minutes, during 
w^hich the heat should be raised to 104° or 106°. I find that a 
gradual increase of heat renders more complete and more durable 
the revulsive activity of the process, and that a greater quantity 



132 . CROUP. 

of blood continues to flow to ihe extremities, and for a longer time 
than when the water, being at first very warm, is allowed to cool 
as the bathing goes on. 

While the bathing is taking place, a portion of ipecacuanha in 
powder, say twenty grains, should be mixed with four dessert- 
spoonfuls of water, one of which may be given for the dose — to 
be repeated every ten minutes until relief is obtained. 

I have observed a great many children, in spasmodic croup, to 
be completely relieved by the first spoonful, which in the mean 
time excited no perceptible nausea, nor exerted any other influ- 
ence save to relax the spasmodic affection of the glottis. Upon 
finding so complete a relief, I have desisted from any further ad- 
ministration of the remedy. The child has fallen asleep, and had 
no return of the symptoms. 

In cases when so fortunate an operation of the remedy did not 
take place, I have repeated the doses until full vomiting has oc- 
curred ; and thereupon have generally had the pleasure to observe 
a cessation, or at least a great diminution of the spasm and other 
evidences of irritation of the glottis. The vomitings here are 
generally of the last ingesta that have become intensely acid, 
together with a considerable quantity of viscid mucus of the sto- 
mach, showing that organ to have been the seat of an acid and 
mucous saburra, which may, doubtless, have as much to do in 
developing the pathogenic train, as the exposure to cold and damp 
that are so generally accused as causes. The relief thus obtained 
by an oppressed stomach, I doubt not, has a great influence in 
restoring the whole pneumogastric nerve and its branches to a 
more normal condition of evolutive and transmissive power, thus 
freeing the subject tissues of the larynx from their dangerous pre- 
dicament. 

It is a curious circumstance, and one calculated perhaps to 
show how large a part is taken in this malady by the pneumo- 
gastric nerves, that emetics often fail to excite vomiting, though 
administered in large doses. This appears to be generally admit- 
ted ; and the physician, in order to meet the emergency, frequently 
finds himself becoming apprehensive as to the audacity of his prac- 
tice ; for large doses of ipecacuanha, of antimonial wine, of tartar 
of antimony and potash, of hive syrup, are found to require many 
repetitions before the stomach becomes sickened. The doses are 
in some examples urged to an extent so dangerous, that one might 



CROUP. 133 

well tremble for the consequences, especially when tartar emetic 
is used. The apology for these dangerous exhibitions is, that 
the stomach sympathizes with the throat to such a degree, as to 
render it insensible to the power of ordinary doses. But what 
sympathy is that which should make the stomach insensible to 
even alarming doses of tartar emetics, save a sympathy of all the 
branches having a common origin from the spinal accessory and 
vagus in the medulla oblongata? Does not this sympathy lead to 
the inference that much of the pathological condition of the larynx 
is due to a qualitative state of the medulla oblongata itself, dis- 
abling it from effecting fully, or equably, the innervation of the 
organs subject to its normal control? Croupal attacks are nearly 
as apt to follow prava ingesta as exposure to the air, and if so, 
then the physician will find a clearer indication for the use of 
emetics, which he will no longer give to the end solely that they 
may promote the secretion and expuition of laryngeal mucus, 
and bring about a favorable detente of the circulation there, but 
that they may rid the stomach of noxious saburra, which is not 
unlikely to lie at the very foundation of the attack, being the 
absolute pathogenic cause of all the symptoms, first disturbing 
the brain, and thence the subject tissues. 

Be this as it may, it is certain that the action of vomiting, as 
well as the sensitive condition called nausea, has great power, 
not only to check the force of the heart's systole and relax the 
capillary resistance to the systemic injection, but to augment the 
mucous excretion of the fauces, the larynx and bronchi, all of 
which is eminently curative in the case. After the operation, 
the spasm is either much lessened, or wholly removed, and the 
infant usually falls asleep bathed with copious perspiration. 

I was taught, so far back as 1812, to make use of alum as an 
emetic for those cases in which the stomach refuses the influence 
of moderate doses of ipecac, antimonial wine, or tartar emetic, 
and I have for thirty-six years accustomed myself to rely upon it 
as the most certain, prompt, and, at the same time, safe emetic for 
croups and catarrhs. 

It is several years now since I published a recommendation of 
the alum emetic, in the Medical Examiner, for which I drew up 
an article on Croup, and I now with great confidence renew and 
repeat the encomiums I then pronounced upon the medicine. 

Many times have I seen very alarming illness brought on in 



134 CROUP. 

young children by tartar emetic, but I cannot remember a single 
sample of any inconvenient result of the exhibition of alum 
powder. 

To a child under a year or two years of age, it is quite safe to 
exhibit a teaspoonful of powdered alum, mixed with a similar 
quantity of honey. Such a dose may be safely repeated in from 
ten to twenty minutes, though it is very rare to find an instance 
in which vomiting is not produced within five minutes of the time 
of exhibition. Children vomiting by this medicine, appear to me 
to recover very soon from the nausea, and without any signs of 
that exhaustion or relaxation that follows a vomiting provoked by 
antimonial wine, or emetic tartar. 

Generally speaking, the dose is productive not only of the ejec- 
tion of a great deal of gastric mucus, but, likewise, of a vast 
expuilion of faucial mucus, which cannot but tend to relieve in- 
flammatory turgescence and engorgement of the larynx proper, 
whose mucous crypts and glandules participate in the therapeu- 
tical influences of the direct contact of alum with the fauces and 
pharynx. 

The article on Croup, in a Treatise on Diseases of Children, 
by Dr. J. F. Meigs, 8vo. 1848, contains so full an account of his 
experience with the use of alum, much of which is coincident 
wdth my own, that I prefer to refer the reader to that work, rather 
than extend these remarks any farther in this place; my design 
being not to write out a full account of diseases of children, — 
but to make some notices and observations of certain of them 
only. 

It appears to me that the indication here, is nothing more than 
to observe with studious care, the progress of the disorder, and, 
upon finding it receding, to do nothing that might in the least 
interrupt the exercise of the favorable tendencies. But if, after 
the bath and the emetic, the skin should be warm, and the pulse 
full and frequent, a vein ought to be opened in order to take away 
a quantity of blood sufficient to bring about the proper relaxation 
of the circulatory force. 

I cannot conceive of the reasoning that should induce a phy- 
sician to trust a crouping child with a bounding pulse, to the the- 
rapeutic conservatism of any method whatever, save that of the 
lancet. The bounding leaping artery at the wrist, is but the 
exponent of the state of branches of the carotids and vertebrals in 



CROUP. 135 

the brain ; and surely if there be a pathogenic power beneath the 
sun, it is that of a rapid, intense circulation in the encephalic 
capillaries. Such a circulation not only evolves the biotic power 
enormously, which is felt by the pathological tissue already 
in danger, but spreads far and wide the fire of inflammation, and 
causes the malady to hasten to the conclusion of its processes. It 
seems to me that one of the rare events in a medical practitioner's 
career, ought to be the losing of a patient with simple spasmodic 
croup — yet certainly many are lost, perhaps, from want of early 
intervention in their behalf. 

I think it highly dangerous to regard all cases of simple spas- 
modic croup as fit to be entrusted to the curative powers of drugs 
alone. I cheerfully admit that vast numbers of the cases yield 
readily to a treatment without venesection. I advocate the pre- 
cept to remember, always, that the lancet aflfords the surest gua- 
rantee of success and safety. 

There is apparently a growing distaste for the practice of vene- 
section, which, whether it be derived from a change in the epi- 
demic constitution of the air, or from the existence of a greater 
wisdom in the existing race of physicians, seems to me apt to 
mislead in certain kinds of cases. 

Pseudomembranous laryngitis, or plastic croup, is certainly acute 
inflammation of the laryngeal mucous membrane, and it is an in- 
flammation so intense, that it gives early rise to the plastic exuda- 
tion which composes the false membrane. This inflammation is, 
in my opinion, often a purely local disorder — indeed, one might 
think it so in most of the cases, should reference be had to the 
manifest state of the general health in the commencement. My 
own recollections of cases impress me with the opinion that these 
most fatal attacks are to the last degree insidious, that they steal 
slowly and unsuspected upon the victim, exhibiting themselves 
under the mask of a slight hoarseness which is disregarded, as 
being at most only a common cold. The child in the meantime 
appears to have neither anorexia nor fever; it preserves its com- 
placency, and even its gayety, until of a sudden an alarm is taken 
upon hearing the croupal sound, in some act of crying or cough- 
ing. This is the signal that assistance is required, and the phy- 
sician is invited to attend. 

Even now the flecks of exudation in the fauces are not always 



136 CROUP. 

to be found, and the fever is either not yet formed, or it is very 
slight. 

This state of constitutional disturbance is too apt to mislead. 
It is this state that attracts the regards of the practitioner, and it 
is upon it that he grounds his therapeutical intention. 

The disturbance is too slight to put him in fear for the constitu- 
tion, and he abandons it to its own tendencies, turning his mind 
to the contemplation of the pathological state of the air-passages. 

If, instead of finding only a slight degree of fever coincident 
with the crouping voice, he should discover a bounding pulse, a 
pulse to be characterized as a synochus fortis pulse, he would 
hardly refrain from bleeding the patient to incipient deliquium. 
Unfortunately, he rests his intention upon a supposed SLIGHT 
augmentation of the force of the arterial pulse. He decides that 
the pulse does not call for the lancet, and he substitutes for it the 
emetic, the nauseant, the bath, the topical application, and the 
aplastic force of calomel. Under such a treatment, the disease 
of the mucous membrane of the larynx makes steady progress, 
and when the plastic exudation comes to obstruct the aspirations 
to a degree sufficient to cut off a certain per centage of the aera- 
tion of the blood in the lungs, a new and commonly fatal train of 
general innervations has begun its march over the prostrate pow- 
ers of the organs. 

It would be better practice to bleed the patient ad deliquium, in 
all cases of recent origin, and showing evidences of inflammatory 
action in the larynx, in addition to the spasmodic state that is 
clearly shown to exist whenever the crouping is heard. 

Under these impressions as to our therapeutical duty in such 
cases, I cannot lay aside my regret for the growing distaste for 
venesection of which I spoke a little while ago — for, whether this 
distaste depends upon an alteration of the epidemic constitution, 
upon fashion, or upon motives relative to the vulgar sentiment 
growing out of the reign of a great medical heterodoxy, I re- 
main fully convinced that these laryngeal inflammations are rarely 
to be safely conducted, except by means of venesection, carried 
to a great extent. 

The power of the lancet over the force of the arterial circula- 
tion, cannot be denied ; and it is of that power of reduction that 
we should avail ourselves under these circumstances. It is true 
that we have a similar, but far less eflective force in the antimo- 



CROUP. 137 

nials, baths, and calomel. Timidity, a proneness to yield to the 
prejudices of the unlearned, and a mistaken reliance upon the 
indications derived from the arterial pulse, are apt to induce us to 
rest our hopes of cure upon the powers of drugs, which the sta- 
tistical reports inform us are not really dependable resources. 

It is probable that the pathological condition in pseudomem- 
branous laryngitis, consists not only in a vitiated state of activity 
in the muciparous glandules and follicles of the air-tube, but in 
a real phlogosis of the corpus mucosum, and its submucous tissue. 
The exu(^tion-corpuscles issue from the inflamed corpus muco- 
sum, and take the place of the epithelium, which is destroyed. 
At the same time that the tube is filling with the exudation, it 
becomes smeared with viscous mucus, and muco-purulent ex- 
cretions. The submucous cellular membrane becomes also infil- 
trated and tumid, so that the ingress of air to the lungs is ob- 
structed, not only by the exudation, but by the viscous mucus, 
and by the submucous swelling; to which should be added as 
another element of the obturation, a positive thickening or en- 
gorgement of the corpus mucosum itself. 

It is extremely improbable that for all these pathological acci- 
dents, an emetic, a nauseant, a bath, a topical application to the 
thorax, or some doses of calomel could prove reliable remedies ; 
and it is highly probable that a bold and prompt venesection, one 
that should weaken the power of the arterial injection very posi- 
tively, one sufficient to keep it down, when once reduced — such 
a bleeding, followed by the emetics, the nauseants, &c. &c., 
w^ould rescue a greater proportion of the children, than are now^ 
saved by the medical ministry. 

As to the use of leeches applied to the region of the larynx and 
trachea, I venture to remark that there are few cases in which the 
system can tolerate the abstraction of blood by them, in which it 
could not as safely admit of a direct depletion by the lancet. A 
venesection is, indeed, a more manageable remedy. In bleeding, 
we may put an instant stop to the jet ; we can suspend the flow, 
while we consider whether we shall let the flow recommence, and 
in the meanwhile we can make our inquiries as to the therapeu- 
tical good or evil of the operation thus far. By venesection, we 
may, in a good degree control, not the force of the circulation 
only, the development force — but, in controlling it, we may in a 



138 CROUP. 

measure dictate as to the degree of the innervative force of the 
whole nervous mass. 

I look upon the uses of leeches as secondary — those of vene- 
section as primary; the topical abstractions of blood are most 
efficacious when they follow, not when they precede, or take the 
place of general bleeding. 

With these views, I conclude that, in the management of 
croupal diseases, in which there seems to be any, or the least 
tendency to plastic exudation, our chief reliance should be upon 
venesection, carried to the extent of incipient deliquiun^animi. 

The amount of disease we have to contend with is trifling; 
perhaps two superficial inches of mucous tissue comprise the 
entire sum of diseased texture; but that superficies, once filled 
w^ith plastic exudation, destroys the patient by cutting off the 
sources of oxygen of the blood. It has, therefore, all the press- 
ing importance of the most furious pleurisy, or the most foudroy- 
ant apoplexy. 

If the patient in pleurisy ought to be bled to save his life, or if 
a physician would open both the temporal arteries, or both the 
basilic veins, for an apoplectic, I see not why he should not ex- 
hibit as impetuous an energy to snatch the threatened victim of 
croup from an imminent death by asphyxia. 

There is little doubt as to the beneficent influence of calomel 
in these circumstances. The dose should be a full one, in order 
that a decided impression should be made by it upon the nervous 
system, upon which its force is that of a sedative; for, not less 
powerful in sedation than tartar emetic, is a full dose of calomel. 
Hence its aplastic property as a medicine. Whatever reduces 
the threshing power of the heart — whatever serves to allow the 
first and second acts to follow each other gently and slowly, is 
aplastic — whatever serves to diminish the vital tension and the 
functional exertion of the endangium, is aplastic ; venesection is 
first in such power, and perhaps tartar of antimony and potash, 
or calomel, second. 

The bath is admirable for the same end. 

It is useful to apply warm fomentations or poultices to the 
throat. 

It is also expedient to unload the alimentary passages by means 
of an enema ; and after the calomel, by means of castor oil, which 
I prefer, as the speediest and most reliable aperient or purgative. 



CROUP. 139 

After the emesis — after the venesection — after the calomel, the 
fomentations and baths — an excellent medicine may be adminis- 
tered, that is called Coxe's hive syrup. Indeed, for more than 
thirty years past, Dr. Coxe's hive syrup has been a standard drug 
in the management of the various forms of croup in Philadelphia. 
Its composition, squills senega and tartar emetic, renders it a 
most prompt emetic; and in a great majority of the cases, it has 
been used as the emetic here. But, as a mere nauseant and ex- 
pectorant, the consumption of the article has been, and is still, 
very great. When given in small doses of five to twenty drops, 
repeated with intervals of an hour, it appears to act very success- 
fully in the direction above named. 

There can scarcely be met in the wide circle of medical obser- 
vation, a spectacle of sorer distress than that exhibited by a child 
during the gradual progress of its suffocation, under an attack of 
pseudomembranous laryngitis. I refer here to that period of agony 
that is observed while the patient yet preserves his sensibility, and 
while the strength is not very greatly reduced, a state that ena- 
bles him to perceive the sensation of approaching asphyxia, and 
to struggle in vain for breath, which cannot be breathed through 
the rapidly closing windpipe. 

This profound misery is lessened towards the close of the case ; 
for, when the non-aeration has reached a certain point, a state of 
anaesthesia is found to come on, in which the victim lies calm 
and indifferent, sleeping his life away, without agony or effort. 

The state of the nervous mass is here not dissimilar from that 
which is superinduced by the use of chloroform and ether, when 
pushed to the anaesthetic extent ; and I have reason to believe that 
dissection or surgical operations, done for an individual under 
such circumstances, give as little pain as when performed under 
the influence of the letheon itself. But, in the middle stages of 
fatal croup, the jactitation, the struggle for breath, and the phy- 
siognomical expression of anguish, are so great, that the spectacle 
is sometimes truly appalling. 

Happily for suffering humanity, there is a power in surgery to 
which we may appeal, in cases that would remain otherwise hope- 
less. I allude to the operation of Tracheotomy, or opening the 
windpipe, in order to let the air dowm into the lungs, when the 
larynx has become too much filled with false membrane to admit 
of its entrance in sufficient volume to aerate the blood in the lungs. 



140 CROUP. 

This operation has been performed with success a great many 
timeS) particularly in Paris. The success is estimated by Messrs. 
Trousseau and Valleix to equal fifty per cent, of the cases in 
which it has been employed. 

Inasmuch as the incision would never be resorted to, but in 
instances wholly incurable by natural or by therapeutical me- 
thods, the saving of one-half of the otherwise inevitably mortal 
cases should be deemed a great encouragement to the adoption of 
the resource. 

So far as I can learn, the operation of Tracheotomy in croup, 
has been performed four times only in Philadelphia, and in three 
of them the patients w^ere not rescued, while in one the cure was 
complete, as well as rapid, and without any notable inconve- 
nience. 

I believe that the failures here had served to dishearten our 
physicians and surgeons, and for along time past no attempts 
have been made to rescue the dying victim by means of the bis- 
toury. 

A recent success in the use of Tracheotomy, as an ultima ratio 
in croup, has been so gratifying to all the persons interested in the 
case, as to convince me that the profession ought more frequently 
to adopt it, under the circumstances proper for it — that is to say, 
in all cases where after a clear, undeniable diagnosis of pseudo- 
membranous laryngitis, the accumulation of false membrane has 
choked the air-passages to an extent that must soon prove fatal, 
unless relieved by means of a surgical operation. 

There is but little danger that any surgeon will be found over 
hasty in the adoption of this course, for there are too many objec- 
tions arising out of the state of feelings, whether in the friends of 
the patient, or in the attending physicians themselves, to render it 
probable a too early resort will ever be had to the bistoury. 

I shall now state a case of the operation, which w^ill better 
show what motives there are to operate, than any mere argument 
that I could put down upon paper. 

George Repplier, an only son, aged four years, was a healthy 
child, being robust and fat. 

On or about the 20th of May, he was affected with a hoarse- 
ness and a cough. His voice became whispering, and his cough 
gave out the croup sound. 

A Homoeopath was called, and gave him, probably, deciilionths 



CROUP. 141 

or some equivalent — nothing. On Wednesday, 31st, and Thurs- 
day, June 1st, his respiration was laborious, and his voice a v^^his- 
per; the croup being much aggravated. On Friday he was very 
ill. On Saturday, 3d, his state was most alarming, until near 
dark, when the Homoeopath was dismissed, and I was sent for. 
Being absent from home, my son Dr. J. F. Meigs was called, and 
found the child affected with all the symptoms of pseudomem- 
branous laryngitis, in the last stages of its progress. 

Hopeless as Dr. Meigs was of being able to render any effec- 
tual aid to the perishing boy, he felt obliged to try some remedy, 
and with a faint hope that it might restrain the rapidity of the 
inflammatory processes still going on in the diphtheritic surfaces of 
the larynx, he applied a few leeches to that region. I reached 
the house just as the leeches w^ere come off. 

The boy was tossing from side to side, flinging his arms abroad 
in his distress. His face was of a modena red ; his lips bluish ; 
his gums and palate white ; his pulse excessively rapid and small, 
and the respiration effected by long protracted efforts of the dia- 
phragm, during which, the air in small quantities was draw^n into 
the chest, and expelled as slowly, and seemingly with as much 
difficulty, as w^as experienced in its inhalation. My idea of it was 
that the calibre of the tube was not one-eighth of an inch in dia- 
meter, and that the boy must die before morning, for I thought 
that such enormous efforts to breathe might alone suffice to con- 
sume the small remainder of nervous-force left by many days of 
membranous croup. 

I could not, upon the most careful auscultation of the thorax, 
discover the least respiratory murmur in either lung, for the re- 
duction of the calibre of the larynx w^as so great, that the small 
quantity of air that permeated the lungs, gave out no audible 
murmur in the bronchi. 

I explained to the father of the child my opinion as to the very 
precarious state of the boy, and both Dr. Meigs and I agreed in 
opinion that he was lost without remedy. 

Nevertheless, we mixed half an ounce of powdered alum with 
four spoonfuls of honey, and gave him one-fourth of it for a dose. 

We were surprised that the first dose did not cause him to vomit. 
In a few minutes, a second, a third, and then a fourth, which was 
the last portion, half an ounce in all, being taken, full vomiting 



142 CROUP. 

came on, with the ejection of large quantities of viscid mucus 
from the stomach, followed by a great expuition of faucial mucus. 
The operation of the emetic w^as very complete, and, as observ- 
able in the use of this article, was not followed by any appearance 
of greater weakness, or exhaustion, but rather by a slight mitigation 
of the distress. Some counter-irritant applications were then made 
to the neck, and he took calomel in five grain doses, which were 
repeated in the course of the night. Dr. M. watching with the 
patient. He took in all nine doses, making forty-five grains. The 
night was most distressing. In the morning, all the symptoms 
being aggravated, and the anaesthesia of cyanosis, or asphyxia, 
being considerably advanced, we informed the father of the child 
that we entertained no further hope for the patient, save such as 
was attached to the Tracheotomy operation, which w^e urgently 
recommended. Both parents accepted our proposition, and Profes- 
sor Pancoast being called as surgeon, that able operator conducted 
the case in the manner described in the followinsf letter to me. 

o 

My Dear Sir: — I send, in accordance wdth your request, a 
brief account of the operation of Tracheotomy, which I was sud- 
denly called by you and Dr. J. Forsyth Meigs to perform on the 
4th inst. We found the little patient in such imminent danger of 
suffocation, and the parents so urgent for the employment of any 
promising means of relief, that we w^ere enabled at once to pro- 
ceed with the operation as follows. 

The child w^as laid on a table garnished with a folded blanket 
and pillow, with his head facing the window, and sustained by 
yourself, your son, the father of the boy, and my student, Mr. 
Horner. I first divided the integument and fasciae, exactly in the 
median line, from the lower part of the cricoid cartilage, to the 
top of the sternum. The inner edges of the sterno-hyoid mus- 
cles were thus exposed. Those muscles were separated, W'ith 
some of the tissue below them, with the handle of the knife, and 
with a few touches of the edge, especially at the lower part of the 
wound, after it had been ascertained with the finger that there 
w^as no middle thyroid artery sent up from the innominata. 

A large vein was found at the bottom of the wound, cross- 
ing obliquely to the right side, which I tied and pushed aside. 
The isthmus of the thyroid gland was now exposed. No pulsat- 
ing vessel being felt in this part, I divided it, with the intention 



CROUP. 143 

of taking up the cut vessels on either side with the tenaculum, 
separately or in mass, in case there was bleeding, which did not, 
however, follow. The trachea, covered with its cellular sheath, 
was now freely exposed for about an inch and a half. This sheath 
I next split up longitudinally, and cross-cut near the larynx, so 
that I could push it readily aside, and leave the trachea well ex- 
posed, without risk of the sheath forming a nidus for the lodg- 
ment of blood or mucus, and presenting subsequently a physical 
obstruction at the opening to be made in the trachea. I now 
with the bistoury, opened the trachea in the middle, dividing the 
fifth, fourth, and third rings. This incision was instantly fol- 
lowed by a spout of mucus and flakes of false membrane, with 
decided relief to the patient. Pausing, with the lips of the orifice 
held lightly apart, until these convulsive efforts had in a mea- 
sure subsided, I raised in succession, with the tenaculum, the mar- 
gins of the tracheal incision, and removed with the scissors a 
semi-elliptical piece on either side, so as to form an oval orifice, 
about three-eighths of an inch long, and one-sixth, or a little more, 
broad. The lungs and trachea were now speedily relieved 
through this opening, of a good deal of mucus and false mem- 
brane, though a regular layer of false membrane, covering the 
back part of the trachea, could still be seen through the orifice. 
A leaden wire, about one-eighth of an inch in diameter, chosen 
for its non-elasticity, was brought round from the back part of the 
neck, and the ends bent to a little more than a right angle, so as 
to take a deep hold near the surface of the windpipe, and draw 
the sterno-hyoid muscles and all their coverings apart, leaving a 
clear gaping wound in the neck, with so much free space above 
the new tracheal orifice, that it was not likely to be drawn up 
under the integuments and obstructed, in gulping or deglutition. 
The leaden wire was then moulded on the neck, so as to rest 
smoothly and easily, without liability to displacement. Thus 
placed, it fulfilled its office well ; for the patient, you will recollect, 
could turn about in the bed, and run round the floor, with little 
inconvenience from it. My intention in resorting to the excision 
of a piece of the trachea, and leaving a defined opening, rather 
than the usual incision of the rings, with insertion of a tube, arose 
from the difficulty which attends the discharge of the tenacious 
mucus and membrane through a curved tube, and the keepintr 
of it clear for respiration, as well as from a desire to avoid the 



144 CROUP. 

irritation which the presence of a foreign body must more or less 
excite. In this instance we were successful in getting a new 
breathing orifice, larger than the rima glottidis, admitting of easy 
respiration, and enabling us to remove with the forceps such 
flakes of false membrane as were too large to be coughed or 
blown out. The size of the orifice was besides luckily propor- 
tioned; for, as it was allowed to close up gradually and sponta- 
neously by granulation in front of it, by the time it became shut 
the ventricles had become cleared of the false membrane, and the 
respiration took place regularly and easily by the natural chan- 
nel, without any evident impairment of the voice. Now twenty- 
one days after the operation, the wound in the neck is solidly 
cicatrized, and the patient is gone into the country to spend the 
summer. I remain very truly, Yours, 

J. Pancoast. 
To C. D. Meigs, M. D. 

June 25th, 1848. 

As soon as the incision was made, the air rushed into the tra- 
chea, and was followed by a noisy explosion of cough, w^hich 
drove out through the aperture a great quantity of mucus, mixed 
with ingurgitated blood, amidst which were portions of false mem- 
brane, w^hich, being seized by Dr. Pancoast with the dressing for- 
ceps, were drawn away. 

Less than half a minute was passed amidst the agitation of the 
first fit of coughing, upon the cessation of which, the child ap- 
peared to be perfectly easy — indeed, his breathing, which had for 
so many days been beyond measure laborious, suddenly became 
perfectly easy, and the transition from a state of suflfocation and 
imminent death to one of perfect ease, was so rapid and complete 
that the father supposed his son to be just dying. 

Dr. Pancoast, wdth admirable judgment, now resolved to re- 
move the elliptical disc from the trachea, in order to make a good 
and sufficient aperture, and not to be under the necessity of using 
the metallic tube. He observed that the metallic tube, worn in 
the trachea, could not but contravene, in some degree, any cura- 
tive tendencies that might follow the operation; and there is much 
reason to attribute the subsequent most rapid cure to this pruden- 
tial and ingenious method of proceeding. 

The following part of the day, Sunday, June 3d, was passed 



CROUP. 145 

in perfect tranquillity by the little patient. Mr. Horner, or Mr. 
Hewson, both of them private pupils of Dr. Pancoast, remained 
near the child day and night, in order to remove by the sponge, 
or the dressing forceps, any portions of plastic membrane or 
mucus that might come to the opening ; and also that they might 
keep the wound carefully open, by freeing it from dried blood or 
mucus that should form troublesome incrustations around the ori- 
fice. A considerable quantity of the pseudo-membranous deposit 
was successfully withdrawn by those gentlemen. 

To the great care and w'atchfulness exercised by Messrs. Hor- 
ner and Hewson, much of the subsequent success, and the total 
absence of inconvenience, is fairly to be attributed. I saw the boy 
on the 19th of June, playing in the street; the wound is closed 
completely, and he has no remaining indisposition, save a slight 
occasional cough, w^hich may perhaps depend upon a remaining 
tenderness of the mucous surface of the trachea, at the point 
from which the disc was exscinded. In June, 1850, he w^as in 
good health, and his voice is perfectly restored. 

To read Dr. Pancoast's account of the operation ought to con- 
vince any one that such incisions, dissections, and ligation might 
give very great pain to a person possessing his ordinary sensibi- 
lity; but the little boy was perfectly tranquil during the whole 
operation, making no complaints, and, in my opinion, not per- 
ceiving much pain, in consequence of the anaesthetic state of his 
sensitive nerves, produced by the very advanced asphyxia, from 
which this skillful operation rescued him. 

The pleasing result of Dr. Pancoast's operation, in this case, 
led to the performance of tracheotomy on the two children of Dr. 
Roper, dentist of this city. In one of the children, the operation 
failed, and in the other was successful. The failure is justly 
attributable to the extension of the plastic exudation into very 
small branches of the bronchi. The tubes of lymph were removed 
after the death of the child, and being still preserved as an ana- 
tomical preparation, exhibit the proofs of what I have above stated 
as the cause of failure, to wit : it shows that the disorder was not 
confined to the larynx, but was a disease extensively affecting the 
bronchial tubes. The aperture made by the surgeon into the 
trachea could by no means admit a sufficient volume of air into 
the pulmonary cells, since even the small ramifications of the 
tracheal branches w^ere choked by the exudation. 
10 



146 CROUP. 

I have recently been the witness of an operation of tracheotomy 
for pseudo-membranous croup, in another case, which proved fatal. 
In that case, it is true that the exudation had affected the ramifi- 
cations of the trachea very far down the tubes ; yet I remain 
inclined to think the case might have had a happier termination 
but for a most profuse hemorrhage that arose during the operation 
from the division of a very large vein. This hemorrhage brought 
on a nearly fatal swoon, during which it is probable that a heart- 
clot w^as formed ; for the post-mortem inspection revealed a very 
firm white fibrinous clot in the pulmonary auricle and ventricle, the 
processes of which filled and extended far onwards in the course 
of the pulmonary artery. It may be the child could not have reco- 
vered from the pseudo-membranous angina. I feel sure it could 
never survive such a heart-clot. The case, therefore, is one of an 
unsatisfactory character, as an item in the statistics of the opera- 
tion — its value being vitiated by the occurrence of the swoon, and 
the consequent coagulation of the blood in the heart. It appears 
to me that, in all cases of tracheotomy, it might be possible to 
preserve the patient from the danger of hemorrhage by a careful 
dissection: the transverse branch, that is most liable to be cut, 
can be secured by two ligatures, the vein to be divided betwdxt 
them ; while the middle vein may be thrust to the right-hand side 
with the handle of a scalpel as the rings of the trachea are being 
exposed. 

It is a distressing duty, that of recommending or performing a 
tracheotomy operation, and the painfulness of these duties is 
greatly enhanced by the absolute uncertainty as to success. I 
hold that we are not, and can never be in any case, competent to 
decide, a priori, upon the extent of tracheal surface that is affected 
by the exudation. Yet where all other hope fails, I should consider 
myself obliged to state the possible advantages to be derived from 
opening the trachea. The only danger attending that operation 
is that from the chance of hemorrhage, which, it seems probable, 
could always be avoided by ligation of the veins. 

The operation is scarcely painful. 

To support this assertion, it seems to me necessary only to say 
that the sensibilities have nearly disappeared at the period when 
the tracheotomy should be deemed advisable. In the case of Mr. 
Repplier's son, I know that the nervous sensibility of the child 
had become so low as to be fit to be called a really anaesthetic 



CROUP. 147 

state of it. Very large and cautious dissection was made without 
drawing from the child the least expression of suffering: and in 
the other case, no struggle, nor the least resistance on the part of 
the little patient, gave me reason to suppose that the surgeon was 
giving great pain. 

To be nearly dead from asphyxia is to be anaesthetized, as truly 
as if from chloroform or ether. If I am correct in these impres- 
sions, and I confide in the careful observations on which these 
impressions are founded, then I may say that a great objection to 
the tracheotomy disappears, at least from my own mind, since I 
might, in the extreme illness of a child, or other, feel unwilling 
to inflict a pang by doing an act that I would cheerfully do pro- 
vided it might be done without pain. 

As to the time for performing the operation, I do not suppose 
that any rule can be laid down, fit to govern in all cases. The 
case itself must make its own rule. A competent physician and 
surgeon is alone able to decide upon the emergency. He will 
perceive whether any reasonable hope remains of a recovery 
through merely therapeutical influences, and his decision should 
be final. I have heard it objected that the operation may be done 
unnecessarily. I admit that such cases might occur, yet I find 
no solid objection on that account, because I look upon the opera- 
tion as nearly painless, and scarcely more dangerous than the 
drawing of a molar tooth, excepting always the risk of hemor- 
rhage, which, as before said, can be successfully guarded against. 

It appears to me that, in a case of pseudo-membranous croup — 
one in which the larynx is much choked up with exudation, and 
also obstructed with great quantities of viscous mucus, always 
found in conjunction with the false membrane — there is but little 
reason to hope for a recovery while the aeration of the blood is 
momentarily becoming less and less perfect from the progressive 
diminution of the current of air through the closing larynx. The 
nervous mass is rapidly losing its power to keep the organs alive 
by irradiating them, through the nerves, with the motor and sensor 
powers. The patient grows sensibly and rapidly weaker, thus 
cutting off* our hopes of any recovery. The want is oxygenation. 
If in such a case we could by any means maintain the oxygena- 
tion of the blood, the nervous mass might therein find the power 
to cure the real malady of the larynx. Let us therefore accept 
the only possible mode of pouring the oxygen into the blood, by 



148 CROUP. 

giving a new inlet to that element through the front of the trachea, 
by cutting out an elliptical segment of sufficient size. 

An objection is sometimes urged on account of the so-called 
ataxic nature of the malady — diphtheritic croup. I cannot regard 
the case as a case of ataxic disease. It is truly one of great fee- 
bleness, but that feebleness depends on the absence of the oxygen, 
and the failure, through its absence, of the innervative force, 
and not upon any ontological principle or essence of the malady. 
In the real ataxic diseases, there are alterations of the crasis of the 
nervous mass — they are essentially diseases of the neurine ; but 
asphyxia is merely a negative proposition — it is black blood in 
the capillaries of the brain. If we take away the black blood by 
substituting abundant injections of oxygenized blood into the 
brain capillaries, the ataxic character disappears. Thus, in the 
case of young Repplier, the ataxy, so called, was extreme — he 
was dying; but, as soon as Dr. Pancoast allowed the oxygen of 
the atmosphere to come into contact with his blood, he was cured. 
In a very few hours, he could run about the chamber, which was 
so shortly before likely to contain only his dead body. He could 
have got up to walk within the first hour. 

As a means, therefore, of enabling the nervous mass to perceive 
and respond to our therapeutical impressions, I should prefer to 
open the trachea, in the just and reasonable expectation that the 
calomel — if you will — with senega ; or the nitrate of silver, might 
have occasion better to display their curative forces in an economy 
capable to receive and prompt to respond to their sanative im- 
pressions, rather than in a perishing and therefore insensible and 
aperceptive mass of matter, half dead already, and everywhere, 
within the range of its failing nervous force. There is little 
ground of reasonable hope to cure any malady wherein the 
functional powers are drooping or dead through failure of the 
centro-peripheric influences, that assuredly cannot be maintained 
save by the proper reaction of oxygen on the neurine of the 
nervous mass. 

I cannot but think, from what I have observed in consultations, 
and from what I have myself felt, that medical men often take a 
most erroneous view of the character of this malady. For example, 
in any case where the supply of oxygen is measurably cut off, we 
perceive signs of great debility, and we are too apt to be misled 
as to this so-called debility so as to employ or reject methods of 



CROUP. 149 

which we should have quite a different appreciation but for our 
misapprehension. 

There can be no examples more illustrative of my meaning 
here, than such as may be cited from the cases of cyanosis 
neonatorum, relieved by turning the child on to its right side. In 
some of these instances, the infant passes in a few minutes from 
the last degree of weakness to a state of active, perfect strength. 
The weakness vanishes before the renewed oxygenation of the 
neurine of the nervous mass consequent on the shutting down of 
Botalli's valve and the immediately following exposure of the 
blood to the air in the lungs. I think that the error consists in our 
usually confounding the ideas inability and debility in our cases. 
The inability is extreme in croup, but may be recovered from, 
as in George Repplier, in a few minutes. From a state of real 
debility, however, one can recover only by gentle gradations, not 
suddenly. A patient exhausted by fever, or by hemorrhage; or 
one weakened by famine, cannot become strong again in a mo- 
ment; whereas, a child in croup, and nigh unto death from the 
laryngeal obturation, might have rosy cheeks within a few hours 
after a good aperture made in the trachea. I conceive that a 
medical man would very naturally find his reluctance to operate 
greatly increased by any opinion of his of the extreme debility of 
the child ; whereas, he would feel less of such reluctance should 
he regard the state of things as characteristic not of real debility 
but only of inability in the patient. 

I should, in any case of pseudo-membranous laryngitis, advanced 
so far as to leave no reasonable expectation of the recovery under 
therapeutical treatment, probably feel obliged to resort to the aid 
of the surgeon, and I should so determine upon a general view 
of the case ; not suffering myself to be guided by any results of 
auscultation of the thorax, which, if confided in, ought perhaps 
to deter one from the operation. 

Auscultation of the thorax is of little use here for purposes of 
diagnosis. In all cases of great restriction of the tracheal open- 
ings, the sounds of the lungs cannot be heard ; at least, my own 
experience teaches me that the respiratory sounds lessen, pari 
passu, with the increase of the membranous deposit on the walls of 
the larynx, and at last wholly disappear. I am of the opinion, 
that greater confidence may be reposed in the results of percussion 
than on those of auscultation, while neither the one nor the other 



150 CROUP. 

can have the least power to disclose to us the extent to which the 
pseudo-membranous exudation may have lined the trachea or the 
branching tubes of it. 

The statistical returns of the tracheotomy operations in France 
serve to confirm me in ray views as to the propriety of resorting 
to it in all suitable cases. 

I have not been inattentive to the argument against the opera- 
tion derived from certain unlooked-for recoveries without that 
resort, and I have myself witnessed the restoration of more than 
one patient, so far advanced in the asphyxia of pseudo-mem- 
branous croup as to have livid hands and feet and cyanosed 
features during several consecutive days. Such recoveries are, 
however, rare in the history of the malady ; and I am not, I hope, 
wrong in supposing that even these instances, above referred to, 
would have been more wisely treated, and perhaps more humanely, 
had an earlier recovery of aerating power been allowed by admit- 
ting the atmospheric air into the lungs by an elliptical opening as 
used by Dr. Pancoast. 

I shall close these remarks on croupal disorders by a concise 
recapitulation : — 

1. Diseases that diminish or hinder the ingress and egress of the 
respired air through the larynx and trachea destroy the patient by 
asphyxiating the blood. In proportion as the blood becomes less 
and less aerated, the nervous force is evolved with less intensity, 
and the power of the organs and tissues fails in the same pro- 
portion. 

2. Spasmodic affections of the muscular organs' of the larynx, 
though less dangerous than the exudative obstructions, are yet 
worthy of the most careful attention, since they may readily lead 
to exudative disease in the mucous tissue of the organ of voice 
and the trachea. 

3. The exudation corpuscles that constitute the plastic deposits 
in pseudo-membranous croup are deposited on the surface in 
consequence of the extreme activity of the inflammation existing 
there, and not in consequence solely of a state of the whole health 
or a state of the blood as a whole. Hence, flecks of lymph, or 
exudation spots, fixed upon the arches, the tonsils, or pharynx, 
ought not to be regarded as signs of a depravation of the mass of 
the blood, or of a dangerous ataxy of the constitution, but only 
as evidences of an intense activity of the circulation and innerva- 



CROUP. 151 

tion of the parts affected. — It is true that this activity of the 
circulation increases the risk from the local disorder. 

4. Inasmuch as a slight diminution of the aperture by which 
the air reaches the lungs leads to exhausting frequency or force 
of respiration, in order that the requisite amount of oxygen may 
be imparted to the blood, and as the lessening of the supply 
strikes at the root of the functions by cutting off the sources of 
the innervations, the patient will be probably lost unless the local 
inflammation and the constitutional excitement, if any, be coun- 
teracted by antiphlogistic treatment. 

5. In resolving upon an antiphlogistic treatment, it is safer to 
be governed by considerations of date, and of exigency, as to the 
degree and prospects of the aeration, than by a state of the pulse, 
color, temperature, and sensibility. 

6. To take blood after the pseudo-membranous deposit is 
already abundantly formed w^ould be useless. The obstruction 
has in that stage become physical, and cannot be removed by 
antiphlogistic remedies ; and the loss of blood could not be relied 
upon as a remedy for the deposit already formed. 

7. Yet, if in a case of croup it should be found, upon due 
examination, that the tonsils and arches, as well as the pharynx, 
are affected with plastic deposit, and if the altered sounds of the 
voice, together with difficulty of breathing, might lead to the 
opinion that the deposit of exudation corpuscles had not already 
gone too far — it would be safe to assume that a venesection carried 
to incipient deliquium might check or even cure the inflammation 
of the trachea, and thus put an end to the further extension of the 
exudative processes. It would be much more probable that a 
patient thus treated should escape from death than one entrusted 
to the curative power of drugs alone. I have met with instances 
of the malady in which the child has discharged portions of tube 
and obtained relief thereby, and such examples are well known 
to occur. 

Now, the expulsion'of the tubular pseudo-membrane could only 
occur in cases wherein the process of depositing it, the inflamma- 
tion, had come to its close, and when the tissues, acquiring a 
healthier grade of action, had either suppurated, or discharged 
behind the layer of membrane a thinner material of exudation, or 
even a natural sort of mucus. 

Nothing is so likely, as I conceive, to bring about this desirable 



152 PERTUSSIS. 

conclusion, as a well-conducted venesection. Hence I should 
not, in all cases, feel that I was acting imprudently to let blood 
for the patient, though I were at the same time sure of the exist- 
ence of the pseudo-membranous lining. 

On the other hand, should the dyspnoea and the cyanosis, and 
the state of the general circulation lead me to no hopeful conclu- 
sions of the kind above stated, I should not venture to recommend 
a resort to the lancet. 

It will always be for me a grievous reflection, that in a case of 
pseudo-membranous croup, the malady will not admit of an ap- 
peal to the lancet — and that, because I feel convinced that the 
drugging practice, whether with emetics or expectorants, or 
mercury, can hold out only the faintest prospects of a recovery. 
There is no time in these rapidly destroying maladies to bring 
about such states of the constitution by means of drugs as are 
required to remove the local disorder. Therefore, when I per- 
ceive the impossibility of a hopeful resort to the lancet, my 
reliance on the medical art, for the cure of the patient, is at once 
struck down. 



CHAPTER X. 

WHOOPING-COUGH, 



The violent and protracted disorder called whooping-cough 
frequently leads to the destruction of the young child ; and even 
when, after great suffering, the health of the patient is at length 
restored, so much anxiety has usually attended the course of the 
malady, that it ought to be regarded as eminently deserving of 
careful study by the practitioner. 

Whooping-cough, or chin-cough, technically denominated per- 
tussis, is characterized by recurring paroxysms of coughing, in 
which the patient makes a long, protracted inspiration, during 
which the lungs become quite filled with air, which is soon 
driven out, not by a single explosive cough or act of expiration, 



PERTUSSIS. 153 

but by a succession of expirations, continued until all the air that 
can be pressed forth is completely driven from the lungs. 

In making the diagnosis of this pertussis, I am content to call 
it and deem it a pertussis, if the inspiration and expiration be 
effected in this manner. 

Generally speaking, the long, protracted indraught of air causes 
a shrill sound, called whooping, to be made by the larynx, which 
is partially closed by spasm at the time. This partial closing 
of the larynx, or its aperture, does not seem to me to be the cause 
of the protraction of the effort of aspiration, since I see in certain 
cases that the quantity ingested is as great when there is no 
audible whooping sound as when that sound is most obvious or 
loudest. 

In sneezing there is, as in pertussis, a very great deal of air 
taken in before the explosion of the out-breathing. Hence, both 
in the act of sneezing and in that of coughing under pertussis, 
there appears to be a necessity for filling the lungs to the utter- 
most, and then for driving out the greatest possible quantity of 
the residual air of the lungs. In sneezing it is driven out at 
once — in pertussis by a succession of efforts. It is this pecu- 
liarity that makes it be called pertussis. 

Sneezing is readily excited by touching the inner surface of the 
nostrils with a straw, or with Cayenne pepper, or snuff, and a 
great variety of sternutatories. It is also for many individuals 
immediately produced by looking at a bright sun. Whooping- 
cough, which presents some analogy with sneezing, arises from 
some other, but as yet unknown cause. They are alike, however, 
in this, that they both require the lungs to be greatly distended 
with air, and then emptied as completely as possible of what is 
called the residual air of the lungs. 

Some persons look upon the cause of whooping-cough as epi- 
demic, and most people have no doubt of its contagious nature. 
It is probable, indeed, that there are few families, and very few 
physicians who do not consider pertussis as communicable by 
contagion, or presence. 

Pertussis, as a general rule, attacks the same individual but 
once ; yet there are met with some exceptional cases of persons 
who have twice suffered from whooping-cough. 

The complaint is so common to young children that it is ex- 
pected that all the children of the community shall have the 



154 PERTUSSIS. 

attack, and the common saying that '^the child has not had 
whooping-cough yet," shows how prevalent is the sentiment that 
the child must have it at some period of its life. Indeed, as far 
as my observation enables me to judge, there are very few adults 
to be met with that have not felt its invasion at some period of 
their lives. 

Is a disease necessarily contagious because all the people have 
either had it, or are expected to have it at some time ? 

I think that children under two months of age are not so liable 
to pertussis as those more advanced. I have, it is true, seen 
children in the month affected with it ; but it has oftener hap- 
pened that when an infant has been born in a family where 
several young children were laboring with the disease, the neona- 
tus has avoided an attack. Hence, I conclude that a very early 
infancy serves to obviate, to a certain degree, the operation of 
the morbific cause. I do not know that children of from six to 
twelve months old are not quite as liable as those of from one to 
six years of age. 

Pertussis comes on as a common cold, with moderate coryza, 
and appearance of defluxion to the throat and breast. It is often 
mistaken for a catarrh during the early stages — for the cough, 
at first, does not assume the spasmodic character I have spoken 
of. That is to say, it is not at first attended either by the whoop- 
ing sound or by the succession of incomplete explosions, continued 
until the last possible effort is concluded. 

Nevertheless, whenever, in a family of young children suffering 
under pertussis, another child begins to cough, or has a slight 
coryza, it is common to consider those symptoms as the com- 
mencement of the attack. 

At first, the paroxysms are not very frequently repeated — 
occurring not oftener than once in every two hours, which will 
give about a dozen paroxysms per day. When the disorder, 
however, is fully formed, the paroxysms of coughing come to be 
repeated twenty, thirty, and even forty-eight times a day ; so 
that, at last, in such severe forms, the child becomes really ill. 

Strong and otherwise healthy children, of two to eight years 
old, do not appear to be rendered very uncomfortable by pa- 
roxysms of pertussis that recur not more than twelve to sixteen 
times per diem. They preserve their gayety and appetite ; they 
engage in their pastimes with the usual eagerness, and sleep 



PERTUSSIS. 155 

soundly; sometimes not waking more than twice during the night, 
to cough ; after which they immediately fall asleep again as if 
nothing had happened. 

So, during the day, a child attacked with whooping-cough may 
continue to be perfectly well, with the exception that it is liable 
to be suddenly seized with the fit of coughing, during which its 
appearance is truly distressing; but in a few minutes, having 
recovered from the fatigue and terror of the moment, it engages 
with alacrity in its usual diversions or pursuits. 

Here we have no fever. If we make auscultation just before 
the cough comes on, we may have a considerable tracheal or 
bronchial rale, which is not discoverable in the intervals, or soon 
after the expuition of the phlegm. 

In short, the child is not sick — it has only a whooping-cough; 
which, in itself considered, is not a much more serious affair than 
would be an equally violent fit of sneezing, reproduced at the 
same intervals. 

Whooping-cough, as such, is a malady of small moment, but 
it becomes severe and very dangerous when it is complicated with 
bronchitis or pneumonia, whether of a lobe or a lobule, and, a 
fortiori, if the patient be seized also with double pneumonia. 
Hence I think that the physician has in general little occasion to 
do more than take care to observe the patient from time to time, 
in order to be aware of the first signs of such dangerous compli- 
cations. 

These complications ought to be suspected whenever the 
patient is found to be feverish, to lose the appetite, to sleep un- 
soundly, and to breathe in the whole intervals too frequently. 
All such events as these now mentioned are alarming, and a 
careful auscultation of the thorax is the only means to be trusted 
to clear up the diagnostics of the case. 

Up to the period when such symptoms as I have above men- 
tioned begin to show themselves, the patient ought not to be 
confined to the house, but, on the contrary, should be taken into 
the open air daily, carefully dressed, however, so as to avoid 
extremes of warmth or lightness in the habiliments ; for doubtless 
many of the complications of pulmonary inflammation with whoop- 
ing-cough are the accidental results of taking cold while affected 
with the specific malady of which we are speaking. 

To observe a child affected with a moderate attack of whoop- 



156 PERTUSSIS. 

ing-cough is to be convinced that he ails nothing except during 
the momentary fits of spasm and expectoration. 

The pulse, the respiration, temperature, color, digestion, and 
intellectual and moral complacency bespeak not the existence of 
a serious lesion of the tissues. Yet in a moment, in the twinkling 
of an eye, the whole physical constitution is agitated under the 
paroxysm, and so in the succession of attacks until the disease 
is gone, the child being in the intervals in good apparent health. 

Does this serve to show that the disorder is nervous and not 
inflammatory? 

From the foregoing it appears that pertussis, in itself con- 
sidered, is a complaint that requires but little therapeutical treat- 
ment, and that the inconveniences connected with it are slight ; 
w^hereas, it becomes a very grave affection if it chance to be 
complicated with other disorders of the respiratory organs. 

It is to be dreaded particularly at those critical periods in which 
the young child is liable to derangements of the digestive organs 
dependent upon the state of teething. A child shall perhaps with 
difficulty get through its second summer, even when its respiratory 
system is unaffected — but it shall with much greater difficulty 
escape the danger that may threaten its existence, under the 
forms of bowel complaint and pertussis combined. 

If, again, during the existence of an attack of whooping-cough, 
the child should be assailed with measles or scarlatina, the danger 
should be at once esteemed very great, since the essentially ca- 
tarrhal nature of the disorder called measles could scarcely in any 
case fail to cause a great and perilous extension of the respiratory 
malady, which is also an essential feature of the pertussis. 

Children who have recently recovered from severe attacks of 
measles are many times found to have irritable lungs for some 
weeks after the apparent recovery. Slight colds are apt, under 
such circumstances, to be followed by fever and a renewal of 
cough and rhonchus or rale. In such a subject, an attack of 
whooping-cough, commencing before the convalescence is quite 
completed, must be always regarded as a serious misfortune, 
inasmuch as the patient will be very likely to be seized with a 
broncho-pneumonia, not readily curable, since the chronical cha- 
racter of pertussis is almost sure to be imparted to the catarrhal 
and pneumonic malady. 

The duration of whooping-cough is variable — it generally lasts 



PERTUSSIS. 157 

at least six weeks or forty-two days ; often it is protracted during 
nine weeks, and there are some children in whom the peculiar 
whooping sound of the cough does not disappear during four 
months. I have seen children who did not recover until full six 
months had elapsed, the cough being all the time characterized 
by the sounds and the manner that give it the name of whoop or 
pertussis. 

And now, the question arises, what is whooping-cough ? That 
is to say, what tissue is the special seat of the lesion of sensation 
or motion that gives rise to the phenomena? 

I cannot perceive that, in a pure, uncomplicated instance of 
pertussis, there is to be discovered any evidence of disease of the 
bronchial mucous membrane, or of the parenchyma of the lungs. 
In all cases, there is, perhaps, some lesion about the glottis and 
the fauces, including the posterior portions of the pituitary mem- 
brane, which, like the causes of sneezing, incites or provokes to 
frequent attacks of the spasmodic cough. 

The child generally seems sensible of the approach of each 
successive crisis, and that consciousness arises, I believe, from the 
gradual accumulation of faucial mucus, and possibly of a small 
quantity of laryngeal viscosities. On such occasions, as the 
paroxysm approaches, it becomes quiet, ceases to run to and fro, 
and to play with its toys or companions. It begins to manage its 
respiration warily, as if fighting off the assault, that would come 
prematurely on if it should breathe fully and carelessly. Hence 
its respiration, for a few minutes before the explosion, grows very 
short and quick, until at last, no longer able to avert the coming 
tempest, it runs to some chair, or to the nurse's lap, and, laying 
hold of any convenient support, down goes the diaphragm to the 
very bottom of the thorax, drawing in after it in its descent a 
stream of air, narrowed so as to become vocal by the coincident 
spasm of the muscles of the glottis, until the lungs, thoroughly 
filled with air, are by a rapid succession of compressions emptied 
as completely as possible, and then filled again and again until 
the irritation is done with. In almost all the instances, it is to 
be noticed that the paroxysm of coughing having been completed, 
the child rests very quietly, though much fatigued by the late 
exertion, and one might expect that it is over for the time, but 
this is not the case ; for, after a few moments of tranquillity, the 
crisis again comes on, and we witness a repetition of the same 



158 PERTUSSIS. 

scene, often effected with greater violence and effort than was 
observable as to the antecedent paroxysm or fit. This second fit 
being done with, the child may be expected to have no further 
trouble until the next regular period, which may be two hours later, 
provided the number of fits does not exceed a dozen per diem. I 
have already said that the number of fits may vary from twelve 
to forty-eight per day. I think I have never known more than 
forty-eight of them to occur in any patient of mine during the 
twenty-four hours ; and I say this with great confidence, since I 
generally advise the nurse to keep memoranda of the returns, in 
all severe cases, in order from her register to be able to derive a 
prognostic. 

After the fit is over, if it be merely whooping-cough without 
complication, the child is well enough. It goes to school, or to 
ride'or to walk ; it takes its meals with appetite, and though some- 
what fatigued with the struggles of the coughing-fits, does not 
present any signs of ill health, except while coughing, or imme- 
diately before or after coughing. It digests well, breathes well, 
has a natural temperature and a real complacency, which forbids 
me to suppose that it is really ill. 

What, then, is whooping-cough ? 

When people ask me this question, as to their children, I am 
apt to reply it is merely the fit of coughing and nothing else ; 
and if the malady should continue to be restrained within that 
limit, I think that nothing is required but a little time, and some 
precautions as to dress, exposure, and diet. 

I do not prescribe any drug, for I do not know any drug that 
can cut short the course of the affection, and am not willing to 
expose the patient to other and dangerous complications by the 
administration of drugs. 

W^hat, then, is whooping-cough ? 

Without pretending to be able to give a definite answer to this 
question, I may venture to declare my opinion again that there is 
not, in the case, any disease of the lungs or fauces or larynx suflS- 
cient to account for the phenomena. I have therefore no other 
means of accounting for the phenomena than a reference of them 
to a state of the nervous system — 1 mean a state of that part of 
the nervous system that presides over the respiratory office. 

It is admitted that the function of respiration is under the 
administration of the medulla oblongata, and I presume few phy- 



PERTUSSIS. 159 

siologists will deny that states of the medulla oblongata or its 
nervous dependencies may give rise to symptoms of disease in 
the subject organs or tissues. 

To refer the cause of pertussis to the medulla oblongata is 
equivalent to calling it a nervous disorder, which is just what I 
wished to do, and in so doing to designate that part of the nervous 
mass which I suppose to be the seat of the malady. 

I do not pretend to say that the medulla is inflamed, or indu- 
rated, or softened, or engorged, or ansemical ; for I do not know 
the nature of the lesion with which it is affected. 

The crasis of the nervous substance or cerebral substance is 
unquestionably liable to frequent changes, affecting its forces or 
susceptibilities. Probably neither the scalpel nor the lens, nor 
the chemical reagent, will ever be able to reveal what these modi- 
fications are ; yet the mind may very well presume to suppose 
that states, whether transitory or permanent, of hypersemia or the 
reverse, shall change the activity of the part so affected. 

The blush on a maiden's cheek indicates a state of hypersemia 
or congestion of the capillaries of the skin there ; such a blush is 
excited by a passing thought, or by the most trivial incident. 
Yet such blush, should it take place in the medulla oblongata, at 
the origins of the spinal accessory nerve, or in the tractus of the 
vagus, might readily be supposed capable to modify the respira- 
tion, even perhaps to the extent of developing a fit of whooping- 
cough or laryngismus. Such a state of the nervous mass would 
be the ipsissimus morbus in the nervous disorder called pertussis. 

In observing the phenomena presented in a case of tubercular 
meningitis or acute hydrocephalus, one will scarce ever fail of 
noticing the repeated blushings or suffusions of face in the now 
insensible or lethargic patient. These blushings never occur 
without some coincident motions of the body or limbs. As soon 
as the red suffusion begins to overspread the face, the breathing 
grows hurried or suspirious ; and the carpo-tarsal spasms, and at 
last slight convulsion of the limbs come to convince us that the 
superficial blush of the face is also a hyperaemia of the brain, 
exciting it to the exhibition of the nerve-force whose signs I have 
above mentioned. 

In the disorder called Kopp's asthma, or laryngismus stridu- 
losus, there appears to me to be reason for supposing the whole 
of the phenomena of the first attack to result from a sudden 



160 PERTUSSIS. 

hypersemia of the respiratory lobe, or medulla oblongata. I 
judge so, because the child is seized in the midst of the most 
active and joyous health. The attack is always eclampsic. The 
salaam is instantaneous — and in a few seconds, the whole pa- 
roxysm being past, the infant falls asleep, and awakes compla- 
cent — gay — in perfect health. 

Now, in this salaam, in the laryngismus, and in the pertussis, 
I cannot discover any structural disease of the larynx, the lungs, 
or the respiratory muscles, that should account for the symptoms. 
Structural disease does not come and go in a moment. But I can 
read in the semeiology of the cases a very clear statement of such 
conditions of the respiratory brain as may account, to my under- 
standing, for all the signs that I see in the cases. For, I can see 
the child on its mother's knee, or while at the breast, and while 
gazing with smiling complacency up to her eyes, seized with 
the salaam or the laryngismus or the w^hoop, pass instantly into 
a condition like that of the dying— and in a few" minutes after- 
wards recover its composure, and manifest all the signs of undis- 
turbed health, which shall continue undisturbed and perfect, to all 
appearance, for one, two, or four hours, or even for a week, a 
fortnight, or a month. This may be repeated again and again. 

I do not feel disposed to extend these remarks any farther at 
present, because I desire merely to convey to my reader the ideas 
that I have indulged as to the meaning of the term nervous, as 
applied to these forms of respiratory disorder. I am far from 
supposing that it is indifferent for the patient's interest w^hether 
we regard the malady as nervous or organic. The decision of 
the question in the physician's understanding must in an eminent 
degree determine the course of his conduct in the case. 

I have already said that I look upon ordinary whooping-cough 
as a mere fit of coughing, which is peculiar not only by the long 
inspirations and the succession of incomplete expirations, and by 
the w^hoop, but also by the periodicity. And I repeat, that if the 
patient have only the whooping-cough, I generally leave him to 
nature for the cure, preferring to entrust him rather to her power 
than to the questionable conservatism of any therapeutics whatever. 
For I feel assured that if my patient has whooping-cough, and 
nothing else, he will undergo a spontaneous cure, much surer 
and easier than any of mine. But if his whooping-cough becomes 
complicated, then I feel called upon to interfere, because nature 



PERTUSSIS. 161 

has already failed in her processes by admitting the complication. 
I can no longer trust a nature that has failed to keep the malady 
in its path, and feel under duresse as to an interference with her 
operations. I am compelled to interfere. 

What is the complication? Perhaps pleuro-pneumonia, per- 
haps broncho-pneumonia has set in — perhaps the pertussis has 
gradually converted itself into, or has participated in the nature 
of laryngismus. Perhaps a mucous or bilious saburra has op- 
pressed the primae viae ; or the intestinal tube is vexed with acidi- 
ties or oppressed with flatus or accumulated residue of digestions. 
Perhaps the heart itself, strained and convulsed under the throes 
and struggles of the whooping paroxysms, has given way, and 
endocarditis, commencing upon the half-ruptured valves, is now 
exerting its pernicious power over the sanguine circulation. 
These are the inquiries that ought to be made, in order that upon 
the results of them may be founded the therapeutical indication. 
How various must be the phases of that indication as affected by 
the stage of the malady, its seat, and degree of violence ? 

If, upon due exploration made, it is discovered that a mere 
neurosis is to be treated, or mere change of rate of action of some 
part of the nervous mass, then an antispasmodic medication will 
be selected. This is very frequently done, and is the reason why 
the preparations of assafetida are so often prescribed, or opium, 
or valerian, or musk, or belladonna, &c. 

For many such instances it is not necessary to go beyond a 
prescription of camphorated tincture of opium, either alone, or 
combined with some expectorant, as oxymel of squills or syrup 
of ipecacuanha. 

In some cases, it is desirable to add to these, or accompany the 
use of them with, a portion of lac assafetida or lac ammoniaci. 

If broncho or pleuro-pneumonia should complicate the whoop- 
ing-cough, the patient should be confined to bed as far as possible 
until the lungs are disengaged. The pulse should be reduced to 
a safe rate by a venesection, if it be admissible, which it will be 
in stout, vigorous children, not yet reduced by fever and irritation 
and fatigue. 

If the venesection be either effected or refrained from, and the 
bowels have been properly moved by a calomel purge, or one of 
oil or senna, then the system should be brought under the con- 
trolling power of the tartar of antimony. This medicine, given 
11 



162 PERTUSSIS. 

in very small doses, citra nauseam, represses in the most signal 
manner the violent perturbation of the circulation. It quells the 
innervative power directly, and through that influence lessens the 
ardency of the blood's motion and influence. A child two years 
old ought to get an 80th or a 100th of a grain for the dose, 
which should not be repeated without first inquiring whether the 
preceding one had excited symptoms of nausea. It is best to 
repeat it only in case no sick qualms have arisen. 

While the child is under the influence of the tartarized anti- 
mony, he ought to be allowed the benefit of an occasional ano- 
dyne dose of laudanum, black drop, morphia, or Dover's powder, 
the last being probably the safest if fever be present. 

I am much gratified with the utility of a practice inculcated by 
the late eminent Dr. Joseph Parrish, of Philadelphia; one on 
which he laid great stress in his instructions to his pupils, as to 
the treatment of certain pulmonary disorders in young children. 

The treatment in question consists in the application to the 
nucha and interscapular region of a liniment or embrocation 
composed of oil of amber, oil of olives, and laudanum. 

It is more than twenty years that I am familiar with its good 
effects in numerous cases, and I very rarely have to conduct a 
case of mucous disease of the lungs in which I do not order this 
embrocation to be applied as above three or four times a-day ; 
and I have very good reason to believe that it is not only a good 
counter-irritant, but, by the inhalation of the vaporized essential 
oil, a useful expectorant and respiratory antispasmodic. I usually 
direct equal parts of these substances to be combined and applied 
with friction two or three times a-day. 

In cases where the cough is accompanied with very copious 
expectoration, and rale, after the acute stage of the complicating 
bronchitis is past, I rely very much upon the curative influence 
of doses of alum. This medicine may be given in the form of 
powders weighing tw^o or five or even ten grains ; the pow^der to 
be mixed with honey to give it the form of a linctus. Or the 
medicine may be compounded with honey and water, as follows : 
B. — Sulphat. alum. Z\] ; 
Mel. despumat. ^ss ; 
Aq. fluvial. Jiiiss vel iivss. M. 

Sig. The dose is a dessertspoonful, to be repeated every four 
or six hours. 



PERTUSSIS. 163 

It appears to me that the patient bears this salutary medicine 
better than some of the other formulas in frequent request, and that 
the influence of it upon the fauces and larynx, as well as upon the 
state of the circulation generally, is highly beneficial. In a con- 
siderable number of patients, it has been the only drug I have 
prescribed from the beginning to the end of the disorder. 

It is expedient in cases of pertussis to regulate the diet of the 
patient. An over-rich and stimulating diet tends to develop the 
gastric and circulatory complications of the malady in a positive 
manner. The child, when the malady is at its highest grade, 
very often throws ofT by vomiting the breakfast or dinner that he 
had shortly before taken, because the spasmodic efforts of screatus 
draw the stomach into sympathy with the distress of the parts 
about the throat, in the same manner as tickling the fauces w'ith 
a feather. is apt to do. This very disposition of the stomach to 
frequent daily disturbance may w^ell be assumed as showing a 
tendency to complications of gastric disorder with the principal 
train, and it suggests wise cares as to the allowance of food. 

Sometimes the expuition or expectoration of viscous mucus dur- 
ing the paroxysms is very abundant ; and in those instances that 
are attended w^ith much wheezing we may infer that a large pro- 
portion of the viscosities find their w^ay into the stomach; indeed, 
some young children cannot be prevailed on not to swallow the 
whole of the product. But the accumulation in the primse vise of 
such quantities of mucous saburra must at length interfere with 
the digestive power, and thus assist in extending the length of 
the morbid train. 

It is probably here that benefit will accrue from the employ- 
ment of the favorite cochineal mixture, which is composed of 
carbonate of potash, gum, and water colored wdth a few grains of 
cochineal — a mixture that has, since I have been engaged in the 
practice of physic, been so much relied on in Philadelphia, that I 
presume there were few cases of pertussis among the children of 
our population in w^hich it was not used, either under the order 
of the physician or as a domestic remedy. It appears to me, 
furthermore, that I have found decided melioration of the symp- 
toms after the exhibition of the remedy, and it is reasonable to 
suppose that such a medication w^ould prove useful by correcting 
the tendency to acidity, and by dissolving the viscous mucus, 
either excreted or ingested into the primse vise. 



164 LARYNGISMUS. 

I have not had occasion to notice the beneficial results obtained 
by the exhibition of belladonna in pertussis, and either through 
routinism or upon reflection, I remain convinced that the narcotic 
and antispasmodic influences of the various preparations of opium 
are not less effectual, while they are more manageable as reme- 
dies, than the other powerful narcotic agents in use. 



CHAPTER XI. 

LARYNGISMUS. 



The word strabismus, or squinting, expresses the idea of a 
certain spasmodic action of the muscles of the eyeball. Other 
words ending in ismus in like manner are expressive of the idea 
of spasm — as, for example, cheirismus, podismus, sphincterismus, 
and tenesmus, which severally mean spasm of the hand, the foot, 
the sphincter muscles, or the whole of the muscles concerned in 
the acts of defecation, as well as part of the acts of a labor. 

The inhalation of the breath, under ordinary circumstances, is 
not accompanied with any sound — but if the inhalation be per- 
formed with violent force, or if the muscles of the glottis should 
be spasmodically contracted during the act of breathing, a sound 
more or less loud is produced. When that sound is much pro- 
longed and is also shrill, or whooping, it presents an example of 
stridulous laryngismus^ In this article, I propose to set down my 
thoughts upon the nature and treatment of the disorder called 
stridulous laryngismus, or Kopp's asthma, or thymic asthma, and 
other names, not necessary to repeat here. 

In the last article, that on whooping-cough, I have in a mea- 
sure explained the views I have long held on the subject of 
certain nervous and spasmodic aflTections ; but, as I hope to pre- 
sent those thoughts more lucidly w^hile writing upon the subject 
of laryngismus, I have to entreat the indulgence of the reader for 
certain repetitions that he will notice in the present chapter. I 
should gladly have tried to avoid reiterating these explanations, 



LARYNGISMUS. 165 

were I not convinced that I should fail to set forth my views 
should I depend upon referring the reader to antecedent pages, 
instead of bringing them again into places where they seem to 
me to be appropriate. 

^Yith these prefatory remarks, I now proceed to say that the 
disorder called laryngismus may be readily mistaken for croup — 
or may be misconceived of as a case of epilepsy — or even, in an 
advanced stage, may be regarded as a sample of tubercular 
meningitis, or hydrocephalus. 

The whole disorder has received its denomination from one 
only of its symptoms, which is the stridulous sound from which 
the name laryngismus stridulus has been applied to it. It ought, 
however, to be observed that, in the course of an entire case of the 
malady, there will be observed many recurrences of the paroxysms 
in which no stridulous sound can be heard — and, as I believe, 
many in which there is not even any laryngismus. 

A child suffering under whooping-cough is violently affected 
with laryngismus, and the indraught of air gives out the loud 
stridulous or whooping sound so well known as a mark of per- 
tussis. Whooping-cough, then, is laryngismus — and it is even 
laryngismus stridulus; yet it is, on the whole, a very different 
disorder from that of which we are treating. 

The foregoing observations, if they are just, may serve to show 
that the title of our malady is unhappily chosen, and is likely to 
mislead us in our pursuit of a true knowledge of the disease. 
They ought also to show that the spasm of the larynx is not the 
real disease we are to contend with, but only a symptom or acci- 
dent of it, and one that is common both to it and to whooping- 
cough, as well as to some other morbid affections, as typhoid 
fever, &c. 

A great many little children are to be met with, who, in the 
first days after their birth, seem to acquire with difficulty and very 
imperfectly, the use of the muscular organs of the respiration; as 
if the unaccustomed machinery could not at once enter into full 
and regular play, but rather had need for a sort of education or 
trial of skill to enable it to do so regularly and perfectly. It is, 
therefore, a very common thing to observe in them frequent attacks 
of laryngismus stridulus, that do them, however, no harm at the 
time, and are not followed by any after evil. Their frequent 
crowing inspiration depends upon the want of co-ordination in 



166 LARYNGISMUS. 

the movement of different parts of the machinery of the respiration, 
and it requires not a little practice or training to bring them all 
into a true and natural and easy consent. 

This laryngismus of neonati is usually recovered of by the end 
of the month ; as if the breathing machinery, which at the com- 
mencement of its extra-uterine life could not work smoothly and 
perfectly, should after a few days or weeks come to perform its 
offices with exact order and the most precise rhythm. In these 
cases, I presume the laryngismus is a chief source of the trouble; 
whereas, in pertussis and in the true laryngismus stridulus, I do 
not suppose the larynx to be the prime seat of the troubled func- 
tion, but rather the brain and the diaphragm. 

Our disorder has been by some persons accounted for on the 
hypothesis that the thymus gland, becoming unnaturally large, or 
overgrown, has in some way interfered with the passage of the 
air along the trachea. But I presume the reader will very 
promptly reject this theory, when he reflects that, if pressure by 
an over-large thymus could obstruct the breathing, it could ob- 
struct it continually and not paroxysmally. The patient would 
be all the time long troubled with laryngismus, and not once a 
day, or week, or month, as falls out in practice. 

But I wish the reader to note (what he shall witness in practice), 
that, in many of the examples of true laryngismus, the patient utters 
no sound whatever, or only a natural cry, and then becomes silent 
until the fit is entirely past. For the most part, the sound made 
by the child is the regular whoop — just like that fine prolonged 
shrill sound called the whoop in pertussis. 

I have noted the sound in some instances to be a mere whisper, 
broken with a momentary vocalism at short intervals during the 
aspiration, until the whole capacity of the lungs being filled up 
with air, the child either cries out with a loud voice, or goes into 
the salaam convulsion, or falls into convulsions like ordinary 
eclampsia, or exhibits merely the uprolled eyeballs, the rigid 
neck, and the podismus and cheirismus. 

The absence of all signs of laryngismus in many of the attacks 
has persuaded me that the larynx is not in all the cases interested 
in the evolution of the phenomena ; but the same observations 
filled me with the conviction that the diaphragm is always most 
deeply involved in the malady, and that it is indeed the principal 
organ affected by the nervous principle of the disease. I have 



LARYNGISMUS. 167 

seen no case in Avhich the diaphragm did not become fixed in 
motionless rigidity, the child meanwhile turning of a livid hue, 
and then lying over exanimate with asphyxia like a person 
plunged into an atmosphere of carbonic gas, or else passing 
suddenly into one of the forms of convulsion or spasm before 
enumerated. 

I do not expect to be misunderstood as to my opinion of the 
grave nature of laryngismus in consequence of my remarks on 
the crowing respiration of infants in the month. Such children 
rarely have been attacked with the violent malady which we are 
considering. 

But, as children approach the eighth or twelfth month, the signs 
of laryngismus ought to be held as always w^orthyof attention — or 
even as presenting very alarming symptoms of a disorder of that 
portion of the nervous system upon w^hich the respiratory innerva- 
tions depend. 

I consider such an attack as evincive of very great danger to 
the child's life ; and even where the attack soon passes off,, 
leaving the patient without any appearance of ill health for many 
days, or even weeks afterwards, the vigilance of the nurses should 
be stimulated by assurances that the paroxysms will be almost 
sure to return, and that w-ith increased violence and greater 
danger to life. 

On the 4th of January, 1847, , a beautiful boy, six months 

old, very ruddy, fat, strong, and full of spirits and health, was 
sitting upon his mother's lap smiling, after having just come 
from a full breast. In an instant, in the twinkling of an eye, he 
made the crowing sound of a protracted inspiration — he had car- 
popedal spasm — his trunk w' as affected with opisthotonos, his head 
rotated to the right in strong extension, the eyes were uprolled 
and to the right, until he became perfectly rigid and still — from 
which state he passed into convulsion, wuth purple face and hands. 
The whole scene lasted not more than three minutes, soon after 
which he slept, and then awoke in the most perfect health and 
gayety. I soon reached the house, and found him without 
symptoms. 

There had been no premonitory stage or sign of this violent 
paroxysm, nor was the attack followed by any the least sign of 
indisposition from the 5th to the 10th ; but, on the 11th of January, 
seven days after the first seizure, the attack was repeated, and 



168 LARYNGISMUS. 

again on the 12th. From this time they were renewed frequently, 
and he expired on the 3d of February, thirty days after the prin- 
cipal seizure. 

Up to a late period of the illness, he showed but small evidences 
of the power of the malady, except while struggling with the 
laryngismus, or writhing with the convulsion. He evidently died 
from the extension of a nervous disorder to the cerebellum and 
cerebral hemispheres. I did not obtain leave to examine the 
nature of the encephalic lesions after his death. 

Inasmuch as my feelings were deeply interested in the case in 
question, and as my attentions to the child were assiduously given, 
I had a great many opportunities to study the character of the 
malady in its .various phases ; and it is with the most absolute 
conviction that I declare I could by no means, in the earlier days 
of the case, find in the state of his pulse or respiration, tempera- 
ture, digestion, defecation, or any of the secretions, occasions to 
which I could refer the paroxysms of laryngismus, with the con- 
sequent convulsions. 

When laryngismus is once begun, it seems to me there is no 
difficulty in accounting for the subsequent lapses that take place 
in the health ; which may be explained by the repeated suspen- 
sions of the aerating processes, under which arrests, the mass of 
the blood grows rapidly vitiate, and in so much, either ineffica- 
cious as to the nervous mass, or absolutely poisonous for it. 

The writers on this malady seem to be agreed that the term 
laryngismus is an appropriate one, though Dr. Marshall Hall says 
it might lead the thoughts of the physician away from a state of 
the general nervous system to that of the larynx. Dr. Marshall 
Hall, in this caveat, very justly dissuades from the idea that the 
malady is topical, as in the larynx proper. Yet he appears to me 
not to have wholly liberated himself from the thrall against which 
he would guard his readers. He speaks too much of, and lays 
too great a stress upon, the idea of the laryngeal element — the 
laryngismus. At least so it appears to me, after careful and oft 
repeated clinical analyses of the phenomena presented by the 
sick child. 

I am persuaded that there is more concern of the diaphragm 
than of the larynx in these paroxysms of so-called laryngismus- 
And I beg to call the attention of the practitioner to the pheno- 
mena observable in all cases of pertussis, in which we have the 



LARYNGISMUS. 169 

most remarkable and stridiilous laryngismus coinciding with con- 
vulsive actions of the diaphragm, and other respiratory muscles^ 
very rarely indeed, yet on some occasions, extending to the volun- 
tary muscles also, just as happens in our cases of laryngismus 
stridulus. 

Now, no man, so far as I know, thinks of referring the violence 
of a pertussis paroxysm to a status of the larynx. On the con- 
trary, it is universal to assign to a spasmodic condition of the 
diaphragm the insatiable indraught of the breath, followed by the 
successive and equally insatiable expirations of it, until, the fit 
being concluded, the patient returns in a few" moments to its- 
play, its food, or its sleep, and is, throughout the entire interval 
between the fits, in a sound and complacent health, as far as to 
any visible signs at least. 

What then is the fault ? Is whooping-cough a laryngeal or a 
bronchial catarrh? By no means ; though it often becomes com- 
plicated with either or both of those maladies, which then are 
accidents that supervene, and not necessarily attendant symptoms. 

I do not perceive any reason why we should make a very 
trenchant difference betwixt the tw^o forms of disorder, at least as 
to their more essential and vital characteristics. I conceive they 
are both categories of a similar affection of the nervous mass 
appropriated to the acts of respiration, and that they are in fact 
nervous disorders. 

In using this phrase, nervous disorder, I do not desire to make 
a vague declaration of some abstraction of the thought — I mean 
a disorder of the nervous mass — the neurine — the very substance 
of w^hich brain, ganglion, and nerve consist. And I will take 
advantage of the opportunity to state somewhat at length the 
opinions at which I have arrived on these points, because I sup- 
pose I shall not clearly set forth my views of laryngismus unless 
I do so. 

In another publication, I have put down my full assent to the 
idea of the physio-philosophers that the nervous substance of a 
living creature is essentially the creature, and that all else w^ithin 
it is composed out of, and lives in and by it, the nervous mass 
alone. That the organs and tissues are developments effectuated 
upon the distal termini of nerves, and in that sense compose the 
machinery by which the nervous mass lives, and acts, and mani- 
fests itself as living. 



170 LARYNGISMUS. 

Without entering into the vain discussion as to whether the 
spinal marrow is a mere fasciculus of nerves passing conveniently 
and safely along the spinal canal to the brain, the common source 
and centre of the living force and so seat of the soul, I prefer the 
dogma that anima est tota in foto, et in qualibet parte tota. 

I do not regard the nervous mass as the soul, neither the force 
developed in it by the reagent, oxygen, as the soul. I know not 
what the soul's essence is, while I believe that it is both im- 
mortal and responsible. 

To me it is sufficient that the human body is united to an 
immaterial soul which exhibits its power by maintaining the 
existence of the body during its union with it, and therefore during 
its union with a physical matter, the nervous mass, to wit. 

But laying aside for the present any further allusion to the soul, 
and coming downwards to the material essences, w^ith the nature 
and actions of which we may be allowed to be more conversant, 
I w^ould repeat the expressions of Lorenz Oken, from the Physio- 
philosophy, at page 328 : — 

1804. " The fundamental substance of the animal is point- 
substance ; but, since the essence of the animal consists in its 
being a sensitive substance, so must it belong to the latter's 
essence, that it be atomic or punctiform. The point-texture is 
equivalent to the sensitive mass." 

1805. * * * * " The lowest animals, such as the infusoria, 
polyps, medusa, or sea-nettles, in short, all myxozoa or mucous 
animals, consist of this point-substance, and are wholly sensitive 
mass.'* 

1806. '' The sensitive mass is called in higher animals, nervous- 
mass. The nervous texture is a conjoined series of mucous- 
granules, which have become albuminous in character. * * * * 
At the first instant of the origin of organic matter, it can, however, 
originate only as infinitely numerous points." 

1807. "Granular or point-mass is, however, an accumulation 
of centres. The nervous mass is, therefore, in accordance with 
the conception of the organic, a repeated, multiplied centre." 

1808. " The animal substance has commenced with the nervous 
mass; thus with that which is the highest, and which physiolo- 
gists have deemed the ultimate mass. The origin of the animal 
is from the nerves, and all anatomical systems are only free evo- 
idtions or separations from the nervous mass. The animal is 



LARYNGISMUS. 171 

NAUGHT BUT NERVE. What it is further, or in addition, is obtained 
elsewhere, or is a metamorphosis of nerves. The mucus of the 
infusoria, polyps, and medusse, is nervous substance upon the 
lowest stage or degree, where the other substances that are therein 
involved or merged have not as yet been perfected in an isolated 
manner." 

In paragraph 1811, he compares the nervous mass to the sun 
as centre of the solar system, the organs and tissues to the planets, 
"and the nerves," says he, "traverse the same like radiating, 
illuminant, heating, and moving ether. It is a positing of the 
centre in the periphery." 

1812. "When, also, the other portions have been form.ed out 
of the identical mass, still the whole animal body is naught but 
nervous mass, only, in a crude or inert condition. There is, con- 
sequently, no point upon the body, on which the nervous pheno- 
mena are absolutely wanting, or where they may not appear 
under certain relations." 

The above citations of the Zurich philosopher serve clearly to 
show his opinion, that the real essential or material union of the 
psychical and physical being exists in the substance which w^e 
call nervous substance ; and in this opinion he is sustained by 
Cuvier, and his expositor Flourens, from the latter of whom only I 
shall here quote a passage, to be found in his Analyse Raisonnee 
des Travaux de Georges Cuvier, p. 88. 

M. Flourens is speaking of the principles of a method in 
natural history, and he says : " La forme du systeme nerveux 
determine done la forme de tout I'animal, et la raison en est 
simple; c'est qu'au fond, le systeme nerveux est tout Panimal en 
eflfet, et que tous les autres systemes ne sont la que pour le servir 
et I'entretenir." 

Such are the expressions of M. Flourens, to whom we are 
indebted, perhaps, more than to any living author, for clear and 
practical views of the nature of the nervous system. For my own 
part, without feeling in general bound to adopt whatever explana- 
tions or rationales of life may be presented to me by men we call 
authorities, I freely admit that there is in me a tendency to sur- 
render my judgment to the dicta of Lorenz Oken, notwithstanding 
the salutary declaration of St. Augustin, " Quod scimus debemus 
rationi; quod credimus, audoritati ;^^ expressions that ought to 
serve as a motto and general declaration of independence for all 



172 LARYNGISMUS. 

persons devoted to scientific pursuits. But of such authorities as 
Oken, it might almost be correct to say, in believing after him, 
quod credimus scimus. 

Taking the foregoing declarations and statements of those dis- 
tinguished physio-philosophers as a basis of physiological truth, 
the question issues from it as to what are the nature and extent of 
the force with which nervous mass is endowed. And here, it 
seems to me, we can arrive at only one conclusion, videlicet, that 
the powers of the nervous substance are dual — impressionability 
and irritability, or vital contractility, depending on a nervous 
force acting upon living organism. 

It is to be observed that I do not here use the words percep- 
tivity and motility, or the words sensibility and irritability. 

In my opinion, it would have been better for the interests of 
such researches, had philosophers universally adopted and retained 
the latter denominations given to these faculties by the illustrious 
Haller, which certainly do in a sufficiently comprehensible man- 
ner, and most concisely express, 1st, the idea that a part of, or 
a whole organism may perceive that it is touched, or changed, or 
affected ; and 2d, that it thereupon can or does alter its density 
through an act of coacervation of its substance. 

This, in fact, is the idea of Francis Glisson, who is the original 
author of the physiological doctrine of sensibility and irritability, 
though, as I have above said, they were firmly established by the 
illustrious Haller. 

Glisson's whole doctrine might be nearly written on one's 
thumb-nail, and is by him thus stated in the Tractat. de Ventric. 
et Litest., cap. vii. p. 147: — • 

"Motiva fibrarum facultas, nisi irritabilis foret, vel perpetuo 
quiesceret, vel perpetuo idem ageret. ***** Hsec autem 
supponit perceptionem et appetitum, ut de novo fibra excitetur. 
Data vero perceptione, appetitus et motus lege naturse conse- 
quentur : ita ut declaratio solius perceptionis fibrarum ad earum 
irritabilitatem manifestandum sufficiat." 

Haller, Physiologia, tom. iv. p. 556, says, "Mihi hactenus res 
liquida videtur, vim contractilem naturalem et insitam musculi, 
a voluntatis imperio augeri." 

Glisson's argument, that the vital activity which we call con- 
tractility, would either be ever active, or, once at rest, would never 
recommence but for a certain perception and appetency that are 



LARYNGISMUS. 173 

indissolubly connected with the facuUy or nature of irritability, 
and Haller's concise statement that the vis insita and the volun- 
tary contractility of muscles are one and the same, the latter 
being governed by the will, are so clear, that no doubt need rest 
on the mind as to the sentiment of those great thinkers ; and I, 
for my own part, feel not at all disposed to go behind those phi- 
losophers to seek for other qualifications of the forces of nervous 
mass than the tw^o I have already mentioned. I mean impres- 
sionability and motility, or what I should be content to see de- 
nominated the sensor and motor powers of nervous mass. 

Intelligent perception is another category ; and it belongs to 
the understanding, to the conscious nature which is the imma- 
terial individuality — the ego — the me. 

As to nervous mass, w^hether it be regarded in its condition as 
cortical or medullary substance ; whether as the material of gan- 
glion, plexus, nerve, or nervous expansion, I cannot suppose it 
endowed with any other faculty than sensation, in itself considered, 
which state of sensation determines in the parts subservient to it 
an act of coacervation ; so that Glisson's idea of irritability, as 
depending upon a natural perception, to which is inseparably 
attached an appetitus and motus naturalis, fulfils the demands of 
my reason on this point. 

Nervous mass exists not alone as such — it is always co-existent 
with organic matter, to which it communicates the power of vital 
motion or irritability. The antagonism of nervous mass with 
organic matter is of the nature of polar force. The sensor and 
motor force are in this sense polar forces. Incident and reflex, 
perceptive and motor — either of these terms is equal to sensibility 
and contractility. 

Sensation is not necessarily conscious or intelligent percep- 
tion, though it may rise to that elevation in the more complicated 
animals; whereas, in the lowest forms of the zoophytes, it scarcely 
exceeds, in the entire animal, the amount of the same faculty with 
which single organs or anatomical systems are endowed in the 
mammifera and man. 

. To possess the power of sensation and motion, it is necessary 
to suppose the coincident existence of a nerve punctum with other 
organic matter; as, for example, in the macula germinativa of 
the germinal vesicle. In this germinal spot, we may fairly sup- 
pose to be seated a perceptio naturalis, in virtue of which the 



174 LARYNGISMUS. 

germinal nucleus determines the series of changing and plastic 
operations that cause the embryonic metamorphoses. So every 
cell which selects or admits its cytoblastem can do so only by 
the force of a point-tissue, whose nature is nervous. 

The nervous mass being the essential animal, then that mass 
determines the form of the animal, and its place in the zoological 
system. The animal is vertebrate, articulate, molluscous, or 
radiate, in consequence of the peculiar form and arrangement of 
its nervous mass ; and it takes its place not only in the division, 
but also in the class, order, genus, and species, and even variety, 
solely on account of the behavior of its nervous mass. 

The nervous mass makes the animal ; of course the nervous 
mass makes the organs of the animal, and maintains their several 
anatomical forms and characteristics during the entire lifetime of 
the animal. 

In this sense, the optic nerve makes the eye, being aided in so 
doing by the fifth and sixth nerves. The eye thus constructed 
is the machinery or servitor of the especial bulb whose most 
dominant and concentrated force is seated in the tubercula quad- 
rigemina; but all the nervous mass of the eye is the eye; though 
the retina, which is the expanded optic nerve, is in truth the 
tubercula quadrigemina produced or protracted in order to meet 
the light at the surface of the animal. 

Another nerve makes the lungs. This nerve, or rather nervous 
mass, is founded in the medulla oblongata, whence radiate the in- 
fluences that determine the action of the machinery of respiration. 
In this sense, the medulla oblongata is the breathing or oxygen- 
ating brain, while the tubercula quadrigemina compose the seeing 
brain. 

Another nerve develops the liver, and it is the bile nerve. 
One makes the spleen — the kidneys — the ovary — the uterus — the 
stomach ; and they ought severally to be regarded as the bile 
nerve, the splenic nerve, the renal, ovaric, uterine, and gastric 
nerve, and so forth to the entire edification and composition of the 
living, sentient animal. 

Is such an animal sick ? is any one of its organs sick ? The 
nerve that composed and that dominates that organ is sick. It is 
impossible to suppose that the organ can be sick through any 
other way ; for the life of the organ is in the nervous mass of it, 



LARYNGISMUS. 175 

and it cannot vary but with the varying crasis or forces of the 
same nervous mass. 

Nervous disorders, therefore, are disorders of the nervous sub- 
stance or mass, whether of the sum or whether of the aliquot 
parts thereof. 

If I am invited to state what are the modifications of nervous 
mass that cause the morbid manifestations of force observed in 
disease, I must reply that I know them not. 

Hardening or softening, hypertrophy, various cephaloraatous de- 
generations, hernia, wounds, etc., are the affections that meet the 
eye of the physician and the necroscopist ; but in the crasis of a 
material so soft as the brain, which has been called the granular 
bouillie of the brain, there may be modifications so fine and delicate 
as to escape the researches of the anatomist and the microscopist 
or chemist, which should yet be capable of giving rise to various 
diseases, psychical or physiological. The scalpel and lens cannot 
detect them; but reason's analysis can know them clearly without 
the grosser aids of the senses, for reason can detect them through 
her observation of the conditions of existence in all cases wherein 
the law of those conditions is broken. 

In studying the various disorders of the human frame, we are 
too apt to confine our regards to the state of the parts in which 
disease is manifest by certain signs — such as inflammation, or 
pain, or weakness, etc. In many disorders, however, we do know 
that, while the symptoms are referable to the stomach, the cause 
may be really existent in the brain, in the uterus, in the mouth, 
etc. etc. The section of a nerve, as is well known, may speedily 
cause hopeless ulceration of the cornea, or red injection of the 
adnata. 

A blow on the head causes an attack of vomiting ; or a saburral 
state of the stomach gives rise to intolerable headache, to vertigo 
or convulsion. Such examples are so numerous that it would be 
a long task to enumerate them. 

In the same manner, certain modes of the brain or the nervous 
mass, of parts of the brain, or parts of the nervous mass, may 
give rise to manifestation of disordered action in the parts domi- 
nated by the special system of nerves. 

I do not fear, in this place, the charge of a leaning to the side 
of phrenology, as referring all the organs, for their dominant of 
nervous force, to some special organ or seat in the brain — thus, 



176 LARYNGISMUS. 

as it were, admitting that the brain is multiple. M. Flourens' 
fine argument on that subject has satisfied my mind most fully; 
nor indeed is there any necessary alliance between the idea of 
phrenological ofgans and the idea of nervus tractus passing from 
the organs to the neurine, even supposing the whole of them to 
be transmitted through the spinal cord, which in that case w^ould 
be only the general fascicle of the nerves of the organs passing 
from and to the brain. 

The occurrences of a long clinical experience might serve to 
show any practitioner innumerable examples of diseases suddenly 
manifesting themselves in the organs of the body wdthout the ante- 
cedent occurrence of any morbific causes acting directly upon 
those organs. Such cases present examples of sudden suspension 
or diminution, or exaggeration of the motor or sensor forces of 
the organs in question. When such disorders disappear in the 
same sudden incomprehensible manner, the phenomena can be 
accounted for by supposing the sudden restoration or redintegration 
of the dominant sensor or motor forces. But where is the seat of 
these dominants of the organs } Are they not resident in the 
nervous mass, and chiefly in the great encephalic bulbs thereof? 

How many times have we seen gout or rheumatism of the 
articulations, exquisitely characterized by the tumor, rubor, calor, 
et dolor of inflammation, yea, even enormous inflammation, dis- 
appear almost as by the stroke of a magic wand, or reappear 
with equal violence and haste in another part ; and so, again and 
again, until many of the articulations have suflfered in turn from 
the irritation ! Is it possible to account for these circumstances 
upon any considerations of an anatomical structure of the inflamed 
parts merely ; whereas, those parts which are maintained in crasis, 
in power, and development by the vitalizing, irradiating, deve- 
loping energy of the nervous mass, are merely the machinery and 
servitors of the living, and only living, nervous mass. 

I have already said that, if I am asked what are the changes or 
modes of the nervous mass that bring about these phenomena of 
diseases, I know them not. But this I do know — videlicet, that 
a man has within him a free-will force, which, by the mere dicta 
of his soul, sends the motor power to his voluntary organs — or 
which, under circumstances of peculiar emotion, gives manifesta- 
tion to the various passions of the soul. That the dicta of the 
free-will, and the turbulent demonstrations of the emotional powders 



LARYNGISMUS. 177 

do coincide with changes of mode of the nervous mass is no more 
deniable than the dogma of the immateriality of the human soul 
and its union with the physical body of man. Yet what fine 
modifications of the nervous mass are those that enable a Grisi or 
a Jenny Lind to hold in rapturous suspense the crowded audiences 
that breathlessly listen to the tuneful modulations of the voices of 
those enchantresses! It is the vocal organ, the larynx, that 
moves — that is affected — that modulates the expression which is 
willed by the soul of the songstress, through a power in that soul, 
to produce modes of the nervous mass whose powers are by the 
nerves radiated to the delicate muscles of the throat. 

A child, smiling upon its mother's knee, apparently in the midst 
of the most exuberant health, is suddenly seized with laryngismus 
stridulus, becomes convulsed, then lies profoundly insensible, and 
soon afterwards recovers its gayety and all its apparent health. 
Where, in this case, is the disease ? Is it the brain that is sick, or 
is it in the throat that the malady is really to be found? If we 
imitate the acts of a patient in laryngismus, which is easily to be 
done, where is the fountain and source of the modifications, of the 
laryngeal function that we voluntarily produce or execute ? Are 
they not in the brain? Is not the brain the material organ by which 
the free and intelligent will operates upon the voluntary organs of 
the nervous mass ? 

I cannot, after the above considerations, discover in cases of 
laryngismus the signs of any other than purely nervous disorders ; 
and when I come to this conclusion, I am prepared already to 
feel no surprise or astonishment when I observe the paroxysms 
to be repeated, to become more and more violent, to be repeated 
at shorter intervals, and be less and less perfectly recovered from 
— to have at last a feverish interval — to observe the intellectual 
faculties more and more clouded, while the body wastes or 
becomes softer and flaccid, and at length to see my patient 
lying in the hopeless apathy of tuberculous meningitis or hydro- 
cephalus : nor yet, when I see him suddenly, as in the twink- 
ling of an eye, cut off — dying in the act of making the accus- 
tomed salaam. 

I have had many opportunities to observe the course of the 
paroxysm of laryngismus. The child suddenly begins to catch 
its breath, as if strangled. In the effort to breathe, the stridulous 
• 12 



178 LARYNGISMUS. 

inspiration is heard in most instances, but not always. The head 
is extended rolled to the right or left ; the eyeballs are strained up- 
wards; the arms and legs become stiff, and the act of respiration 
seems to be suspended, as if some power were interfering with the 
further descent of the diaphragm. In fact, the diaphragm, after 
having descended perhaps only a half-stroke, stops as if seized 
with spasm. It comes to a complete stand-still, and neither re- 
laxes nor contracts any further. The larynx, in the meantime, 
is not drawn downwards along the throat ; but the whole body 
becomes statue-like, as if all the muscles w^ere suddenly affected 
with cataleptic spasm. At length, when the blood, upon this 
suspension of the aerating process, has become sufficiently dark 
or venous, relaxation of the cataleptic rigidity takes place, which 
is very likely to be followed by general convulsion of the trunk 
and limbs, after which the child, becoming quiet and insensible, 
passes gradually into a state of sleep, and wakes again without 
indisposition. 

Having many times observed this process, I feel quite sure that 
my description is correct ; for I have noted the several steps of this 
process in the naked child, holding my hand upon the epigastrium 
in order the more surely to ascertain the state of action of the dia- 
phragm — and I repeat the assertion of my belief that the diaphragm 
is the chief organ affected in this laryngismus stridulus, and that 
the affection is of the nature of the cataleptic rigidity and fixity of 
muscles. Dr. Good, Dr. Marshall Hall, and others, denominate 
the disease as I have done after them, laryngismus. Were I 
authorized to propose a name for the malady, I should greatly 
prefer to call it phrenismus — as indicating the real seat of the 
organic trouble. I do not mean in this to dissent from the opinion 
that the larynx is spasmodically affected in such a manner as to 
cause the stridulous sound of the inspiration, but I do deny that the 
crisis of the paroxysm depends upon the absolute closure of that 
tube, and a thereupon consequent suspension of the respiratory pro- 
cesses; and I assert that the arrest or suspension of the respiratory 
act is due to the cataleptic spasm of the diaphragm itself and of it 
alone, instead of to the closure of the larynx. I have earnestly 
observed the larynx during the paroxysm of laryngismus to learn 
whether or no it descends towards the bottom of the throat during 
the supposed closure of the glottis, and I have always found it to 
be quite still. If the diaphragm should continue to contract while 



LARYNGISMUS. 179 

the larynx should be closed by spasm, the descent would be very 
decided, as I have seen it in cases of suffocation by foreign bodies 
in the larynx, and in pseudo-membranous croup. This proves, 
as I suppose, that the diaphragm is more in fault than the larynx. 

Having frequently in the spasms of the limbs in cholera, in the 
spasms of the masseter and temporal muscles in the locked jaw 
of hysteria, observed the instant resolution of those spasms or 
cramps upon the application of cold to the affected muscles, I 
have pursued the same plan of treatment for obviating the pa- 
roxysm of laryngismus, or rather, phrenismus. 

As soon as the patient gives evidence of the approach of an 
attack, I direct a lump of ice, wrapped in a handkerchief or nap- 
kin, to be applied to the epigaster and moved along the arch of 
the hypochondria. It will be almost universally found that the 
touch of the ice resolves the spasm or cramp of the diaphragm, 
and that the child begins immediately to cry, and that without 
laryngismus, and without passing into convulsions. 

This practice I have repeated so often with my ow^n hands, and 
have so often directed it by other's hands with similar effects, that 
I most confidently recommend it to the reader as applicable in all 
such cases, and as a most desirable method of causing the fit to 
abort. 

If we Ciin, in any instance of the attacks, cause the paroxysm 
to miscarry by reestablishing the suspended respiration, we shall 
in so far tend very stoutly to the recovery of the patient. Every 
successive paroxysm passing into general convulsions is most 
mischievous to the nervous mass, and aids to spread the disorder, 
at first located solely in the medulla oblongata, to the cerebellum, 
and so to the cerebrum and the whole encephalon. 

It has been supposed that an attack of laryngismus would be 
impossible in a person in whom an eliptical segment should have 
been previously removed from the trachea as in laryngotomy ; and 
I have heard it asserted that epileptic convulsions could not occur 
in such persons. If we can cause the fit to abort by means of 
ice placed on the epigastrium, as has been proposed, we shall 
make use of it as a much preferable method. 

Assuming for a moment that I am correct in asserting that the 
primary acts or modes of this disease (laryngismus) are resident 
in the medulla oblongata, the seat of the respiratory or oxygenat- 
ing power, and that the first outward manifestations of it are to be 



180 LARYNGISMUS. 

seen in the stridulous respiration, I have no difficulty to trace up 
the succeeding steps of the paroxysm. 

Let the diaphragm, upon a partial inspiration, be affected with 
the cataleptic spasm that I proposed just now to denominate 
phrenismus — let the rima glottidis be at the same moment par- 
tially closed, so that the patient shall remain for ten or even fifteen 
seconds without the least respiratory act, and I see the blood ra- 
pidly changing from red to black, passing slowly and languidly 
through the heart, and reaching the brain without its endowment 
of oxygen! — what next? — the next step is either an extinction of 
life, or an irregular and convulsive innervation of the whole mus- 
cular system, wdth comatose insensibility, and all the marks of a 
great cyanosis. These are the steps or train of the symptoms. 

In the convulsions of the puerperal eclampsia, the train of 
events is different. In that case, the heated blood is driven in 
rapid streams into the encephalon — which is over-excited by the 
excess of oxygen it receives, and over-stimulated by the repeated 
ictus cordis transmitted through the arteries and capillaries. 
Under such circumstances, intense but irregular muscular action 
is excited — sometimes even while the patient is in the act of 
speaking or using her free-w411 force to bear down the labour- 
pain. It very soon happens, however, that the course of the blood 
becomes checked in consequence of the spasmodic state of the 
respiration, and the fit ends in a transitory cyanosis. In laryngis- 
mus, it begins and ends by a commencing and ending cyanosis ; 
for in laryngismus, the first act consists in the contraction of the 
diaphragm and glottis to a certain point, at which both become 
fixed by cataleptic spasm, and thence the following train of black- 
ening blood, convulsive state of the general muscular system, and 
comatose insensibility, passing either into natural sleep or issuing 
in death. 

In the foregoing statement of my views as to the paroxysm of 
laryngismus, I have depicted the fit as it does most ordinarily 
occur. It might be that the reader should find a discrepancy be- 
tween this account and a correct one of the salaam convulsion, 
and thus question the correctness of my rationale. 

The salaam convulsion is laryngismus under a peculiar form. 
The patient is suddenly seized with the stridulous aspiration, 
and as suddenly flexes his w^hole body — bending the head down 
towards the knees, and that wdth such violence as to strike the 



LARYNGISMUS. I8l 

forehead forcibly upon the floor if he happen at the time to be 
sitting upon it. If the child should be in the nurse's arras at the 
time of the attack, he makes the stridulous sound of laryngismus, 
and immediately bends his head forwards in a bow to the knees, 
resting so, immovable, until the fit goes off, or until several con- 
vulsions take the place of the flexional or emprosthotonic move- 
ment. To be thus suddenly affected with flexional convulsion is 
proof positive that the cause of the malady is in the brain or spinal 
cord, implicating it partially — and while one partial implication 
might produce a complete emprosthotonos, another should cause 
distortion to the right side or to the left side, as the case might be. 
The experiments of Mr. Flourens, in slicing away the brain, show 
that it is in the power of the experimenter to give this or that form 
of muscular action at will. 

Although salaam convulsion is a less common form than the 
other, either form of laryngismus is met with sufficiently often to 
show that the malady, in either case, is one of the nervous mass 
of the encephalon, suddenly arresting the process of aeration of 
the blood. 

I have, w^hile penning this paragraph, a remarkably beautiful 
boy seven months old under my care, laboring with attacks of 
salaam convulsion and laryngismus stridulus. 

Soon after his birth, he was seized with crusta lactea, which 
gave rise to excessive irritation, thougli it did not appear to inter- 
fere with his nutrition, as he grew very fat and strong notwith- 
standing the wakefulness and the frequent fits of crying caused by 
the itching and pain of his eruption. At the age of five months, 
his crusta had very nearly disappeared. After this, he w^as at- 
tacked with severe coryza, which interfered with his ability to suck, 
and caused so great an obstruction of the nostrils that nearly the 
whole of his respiration was carried on through the fauces. 

The severity of the coryza having abated, I concluded I should 
have no further cause of anxiety as to the patient, when suddenly, 
on the 5th of February, he was seized with convulsions while 
playing in his mother's arms, soon after having taken the breast, 
at 8 o'clock P. M. A second attack occurred on the 6th, at 6 
A. M., and a third at 6 P. M. of the same day. This attack was 
very severe. April 5th, 5J A. M., he had a fourth attack, which 
ended in a deep, calm sleep, from which he awoke in apparent 



182 LARYNGISMUS. 

health. The fifth seizure took place on the 10th, at 8 A. M., and 
the sixth on the 19th, at TJ A. M. 

On the 25th, at 4J P. M., he was violently seized \Yith the 
laryngismus and salaam while in the street in his nurse's arms. 
In this instance, the attack appears to have been brought on by 
his sudden terror at the sound of a noisy cart driven along the 
street. It was complete salaam, but attended with laryngismus 
stridulus. 

May 4th, his eighth paroxysm occurred at 6 P. M. The ninth, 
which was violent, took place on the 11th, at 5| P. M., and the 
tenth at GJ P. M., of the 20th May. The latter was mild— the 
child fell asleep as soon as his feet were plunged in warm water. 
He slept favorably during that day, and was very cheerful and 
gay after it, with good appetite, glowing cheeks, bright, laugh- 
ing eyes, and every appearance of perfect health save a slight 
coryza, from which he has never been quite free, and some 
symptoms of a return of the crusta lactea on the face. He suf- 
fered a slight attack on the 21st of June, and another on the 5th 
of July. In both these cases there was no whoop, but only a sud- 
den, sharp outcry, or rather scream — ^just as the salaam came on. 

In the foregoing relation, I have not laid any particular stress 
upon a circumstance which, nevertheless, appears to me worthy 
of a mature consideration — I mean to allude to the coryza. 

If, at any time, one closes the lips of the child by pushing up 
the chin so as to compel the lips into close contact, the boy is im- 
mediately affected with dyspnoea to that degree as to oblige him 
to struggle violently to get his mouth open. He does draw a 
small portion of air through the nostrils, yet not enough to aerate 
his blood properly. In sleeping, in sucking, &c., when the 
respiration cannot take place by the fauces, it is imperfectly 
effected through the nares — and so, I imagine that, in a long 
succession of days, the infant evinces the evil influence of an in- 
complete or non-competent aeration. Upon the failure of a com- 
petent aeration may be founded certain modifications of the blood, 
and certain coincident conditions of the nervous mass, bringing 
the latter, at length, to a point at which the convulsive phenomena 
of laryngismus begin to manifest themselves. 

I am confident that convulsions frequently occur from transi- 
tory attacks of cyanosis neonatorum, and that they depend on the 



LARYNGISMUS. 183 

faulty aeration of the blood in the paroxysm, and cease on the 
return of the circulation through its proper channels in the heart. 

Without being so confident that in W. T.'s case, above stated, 
there is a direct connection of the laryngismus and salaam with 
an obstructed respiration by the nares, I deem the observation of 
sufficient importance to be worthy of attention, and I make it with 
the hope that some other observer may take the pains to consider 
what relation, if any, does exist betwixt laryngismus and coryza. 
Certainly, if enlarged thymus could reasonably be accused of 
giving rise to the fits, they may as reasonably be supposed to 
arise from obstructed nostrils. T am the more led to attribute 
importance to this rationale than I should otherwise be, by the 
facts of a case lately under my care in this city. 

It was the case of Miss * * * *j Clinton Street, affected with 
typhoid fever. When she had become very ill, she was seized 
with symptoms of typhomania, and had the most violent assaults 
of a combination of pharyngismus and laryngismus with phre- 
nismus, and rigid spasms of the limbs. Her life was despaired 
of by very good judges — especially founding that opinion on the 
tonic spasm of the arms. 

Sitting by her one day, and perceiving that she breathed through 
the fauces only, I shut her lips together and then learned that the 
irritation of the stomal and faucial mucous membranes had ex- 
tended itself also to the nares, and that she could scarcely make 
even the smallest aspiration by the nostrils. This arose from the 
collapse of the Schneiderian surfaces in consequence of their 
inflammation. 

I took a camel-hair pencil, and having dipped it in a glass of 
water, I repeatedly put it in each nostril in order to bathe or bedew 
the dried and half-crisped surfaces with the cooling liquid. 

Upon effecting my purpose, I discovered with pleasure that the 
young lady could breathe with greater ease, and that she was 
manifestly soothed and relieved by the ministration. 

The above sickness lasted about seventy days ; during some 
ten or fifteen of those days, she required very many times, daily 
and nightly, the application of the pencil dipped in water to re- 
lieve her breathing. 

No doubt was left upon my mind, or on those of her family and 
friends, that the effect of this humectation of the mucous surface 
of the Schneiderian membrane was most signal in the relief of 



184 LARYNGISMUS. 

some of the worst symptoms of the young lady ; and it was evi- 
dent that too long a delay in the re-application of the remedy 
ahvays left her exposed to renewed attacks of the pharyngismus 
and other spasmodic states of the muscles of the throat. Her 
recovery, which by many could not be hoped for, is in my opinion 
to be attributed in the main to this particular care. Without it, 
the oxygenation of the blood must have grown less and less com- 
plete, to the ultimate overthrow of the great functions of the cir- 
culation, the respiration, and the innervation. 

I think it cannot be too frequently repeated, or remembered, 
that the powers of life in the mammifera exist within a triangle, 
at w^hose angles are severally placed the brain, the lungs, and the 
heart, or the innervation, the oxygenation, and the circulation. 
Such is the great doctrine of Bichat, whose exposition of this 
single doctrine ought to give him immortal renown, even were 
his claims confined to this sole philosophical service. 

But if it be true that life exists within this triangle of the circu- 
lation, respiration, and innervation, and that life cannot cease save 
by the abolition of one of these three elementary powers, whose 
abolition is almost instantly followed by that of both the others, it 
follows, as Bichat says, that we may die because the innervation 
ceases, or because the respiration (oxygenation) ceases, or be- 
cause the circulation is arrested. 

Whatever circumstance contravenes either of these great and 
primary acts of the life tends to induce death ; and I doubt not 
that in very young children, or in adults reduced to great weak- 
ness by disease, the often unnoticed obstruction of the respiration 
brought on by coryza, or by engorgement or submucous infiltra- 
tion of the Schneiderian membrane is the determining cause of 
the fatal issue of the cases — results that might perhaps be obviated 
by attention to the Schneiderian membrane like that I bestowed 
in Miss * * * * 's attack of typhoid fever; and in many other 
instances, some of which I have related in my tract on coryza in 
the earlier part of this volume, and in my article on coryza in the 
work entitled "Obstetrics, the Science, and the Art." 

The treatment of laryngismus must always depend upon the 
special indications of the cases ; and these must vary greatly in 
view" of the hygienic circumstances, the age, constitution, and 
topical malady of the sufferer. 

It has happened that several children of the same parents have 



LARYNGISMUS. 185 

been assailed with the disease, which might naturally lead to the 
inference of a heritable tendency in such children — or to the idea 
that the mother's milk causes the derangement of the health. 

It might well be supposed where many children of the same 
parents perish with this peculiar form of nervous disorder, that 
they had been endow^ed, ah initio, w4th a faulty nervous mass, 
which at the proper age should lead to the explosion of the con- 
vulsive attacks. If a child may inherit blue eyes, or red hair, or 
a sixth finger, or a tendency to scrofula, or gout, insanity, or a 
bad or a good temper, it is not difficult to conceive that it might 
in like manner in the very origin of its life obtain an impress, or 
a tendency of nervous character that should expose it to a great 
risk from the assault of laryngismus. 

Should we then, in any case, have reason to fear a heritable 
disposition to the malady, w^e should, as far as circumstances 
might warrant, oppose and change the natural propensities of the 
patient in this way. 

The character of the future health depends in a considerable 
degree upon the mode of bringing up the child, as to its nutrition, 
dress, exposure, &c. &c. 

Should the heritable tendency be supposed to descend from the 
father, it w^ould be futile to take any precautions as against the 
mother's influence; but if they should seem to come from the line 
of the mother's family, then it would be but a duty to w^ean the 
infant from her breast, and bring it up at another woman's. 

We certainly do meet in practice with families of young chil- 
dren that thrive in the ruddiest health under the care of a wet 
nurse, whereas, such of them as had been suckled by the mother 
were never w^ell, or some of them were even lost, and that solely 
because the mother's milk always disagreed, and so laid the 
foundations of fatal illness. 

Now, inasmuch as we are likely to be much at a loss to decide 
upon the true cause, the ipsissimus morbus in some of our laryn- 
gismus cases, it might be well always to weigh the question as 
to w^eaning the child wholly from the breast, or giving it another 
nurse. This is a question not for me to decide in this little work, 
but for the physician in the special case ; and I shall confine my 
remarks upon it to the mere act of presenting it as one of the 
items, which he alone is competent to judge of, but which it will 
be his duty in all instances to consider. 



186 LARYNGISMUS. 

Many children being provided with wet nurses in consequence 
of the inability of their own mothers, it might well be that such a 
nurse should give a kind of milk unsuitable for the child, and, 
therefore, be the prime cause of the nervous disorder. 

Such a wet nurse ought to be changed for another, if upon due 
inquiry no other probable cause could be discovered. It is very 
certain that a wet nurse has been known to render her nursling 
ill, or even to cause its immediate death, by suckling it when she 
herself has been greatly overheated by exercise, disordered by 
improper food, or rendered half wild with passionate rage. 

Under all circumstances, a just regard to the interests of the pa- 
tient demands that very judicious and precise instruction should 
be given in regard to the diet, dress, and exercise or labour of 
the sick child's nurse. 

A child might be supposed to suffer an attack of laryngismus 
because it lives in a damp, unwholesome chamber or quarter ; 
and as it is well known that the health of the child greatly de- 
pends upon the purity and the moisture or dryness of the air, as 
w^ell as upon the light it enjoys, let a careful attention be paid to 
all these circumstances — changing a lower for a higher chamber, 
a damp and dark for a dry and w^eil-lighted one, or one ill venti- 
lated and close for one wath abundant means of ventilation and 
light. Changes, indeed, of the residence from town to country, 
or from the river-side to the hills might very properly enter into 
the list of measures for the cure. 

, Children are often wrongly dressed. In my tract on dress, I have 
already offered some remarks that I shall not repeat in this place; 
but I beg the reader, who may chance to feel any interest in these 
notices of laryngismus, to turn to page 87, where he may find my 
opinions set forth as to this important item of management. 

A careful attention should be paid to the state of the bowels, 
w^hose condition cannot but influence in a good degree that of the 
nervous mass of the child. A saburral state of the primai vise, 
or a condition in which the intestines are constantly vexed with 
acid or bile or obstructed with mucus, should be obviated by 
means of proper aperients. 

An occasional dose of hydr. c. creta, followed by a portion of 
castor oil or by magnesia, or syrup of rhubarb, will be as likely 
to prove efficacious as any articles of the materia medica. When 
there appears no occasion for the use of purgatives or aperients, 



LARYNGISMUS. ' 187 

the acidities should be counteracted by the exhibition of lime- 
water with milk or with some aromatic distilled water, or by 
means of a potion containing soda or potassa. 

Should the attacks coincide with the crisis of dentition, the 
state of the gums should be observed in order to ascertain whether 
their tension and engorgement ought to be relieved by the use of 
the gum-lancet. There appears to me to be no necessity, nor 
even propriety, in the recommendation made by one author, who 
advises us to cut the gums daily, or even thrice a-day. I cannot 
believe that teething is the cause of laryngismus, however much 
it may conduce to favour the operation of the real causes of that 
malady. 

Since the sudden disappearance or recession of certain eruptive 
diseases has been observed to precede the attack of nervous or 
inflammatory disorders, it is well, in those instances of this malady 
that coexist with crusta lactea or certain forms of impetigo, to be 
on our guard against the danger that attends their too sudden dis- 
appearance, so as to desist from the use of external applications 
calculated to repress the determination to, and nervous excitement 
of the skin. 

I have no doubt resting upon my own mind as to the power of 
such affections as contravene the aeration of the blood to develop 
in the nervous mass a condition that may result in seizures of 
this strange malady, and of other very grave affections. Thus a 
chronic coryza or a moderate bronchial catarrh might, slowly and 
unsuspected, bring about an impure or imperfectly aerated state 
of the blood ; that should be cured first, if we would at last cure 
the carpo-pedal spasm and laryngismus, of which it was the 
original basis. 

In very young subjects, the sudden lifting of the Botalli valve 
by allowing portions of venous blood to escape directly into the 
systemic circulation might also give rise to a degenerate condition 
of the nervous substance. Let the child then be generally laid 
on its right side, not on the left. 

In a child that enjoys good apparent health, except as to these 
periodical attacks, I should consider it desirable to draw blood 
by means of a few leeches applied at the upper part of the neck 
or upon the mastoid regions. 

The uncertainty that must always exist as to the times of 
return, makes it doubtful whether we ought to employ the anti- 



188 LARYNGISMUS. 

spasmodic remedies; and the same difficulty attends the exhibi- 
tion of sulphate of quinine. Perhaps in this case, as in an 
ordinary tertian ague, we might avert the disposition to spasms 
and convulsions by straining the nervous power up to a certain 
degree of tension by means of the sulphate of quinine, if w-e could 
make any reasonable calculations as to the day or hour of the 
return. But young children will not well endure to take con- 
siderable doses of that drug for a long series of days, and the 
small doses we could safely venture to exhibit would probably 
prove of little avail. 

I have directed, however, moderate doses of the fluid extract of 
valerian to be given several times daily for many consecutive 
days, and, as I suppose, with sensible advantage ; yet not so great 
as to enable me to speak w'ith confidence as to its efficacy. Still, 
as the therapeutical properties of the valerian render it one of the 
very best articles for a purely antispasmodic medication, I should 
prefer it to the others, and particularly to the assafoetida, which 
seems to disagree with the stomach, and to be at the same time 
too heating or exciting. 

The iron by hydrogen is one of the most convenient tonics that 
we possess, and it is at the same time one of the most powerful, 
by its influence on the hsematosis. My opinion that the nervous 
disorder is intimately connected with and dependent indeed upon 
a state of the blood and its delimitary membrane, the endangium, 
has induced me, where I deemed a tonic treatment desirable, to 
make use of this invaluable article. For a child less than one 
year old, only a very small dose of iron is required ; and I have 
directed that a small portion should be allowed to adhere to the 
end of a moistened finger, from which it is conveyed to the child's 
tongue ; in this manner, about a quarter of a grain may be given 
three times a-day, and that I deem to be a sufficient quantity, since 
I find that doses not exceeding two grains of the iron are quite 
sufficient to produce the most strikirlg effects in adults. I believe 
that much benefit has been derived from the exhibition of iron as 
above, in one of the cases under my care. Still, I speak without 
confidence, and rather as suggesting a resort to the medicine than 
as advising its use from multiplied instances of its success. Few 
are the physicians w^ho can boast or rather complain of being 
charged with the conduct of numerous cases of laryngismus 
stridulus. 



LARYNGISMUS. 189 

I have, perhaps from long habit and use, great confidence in 
the efficacy as an antispasmodic and stimulant, of the oil of 
amber, and I advise the young reader, who may be doomed to 
experience the embarrassments likely to arise in every one con- 
ducting these strange mysterious disorders, to recommend daily 
frictions of the nucha and the whole interscapular region with oil 
of amber combined with laudanum. 

If such a treatment should not prove agreeable to the practi- 
tioner, or should it be rejected on account of the disagreeable odor 
of the oil, let him cause daily the application of sinapisms to the 
spinal region — making the plasters sufficiently weak to avoid 
exciting too much pain or redness, and repeating them twice 
a-day or oftener. 

Blistering plasters are so very painful to young children that I 
rarely bring myself to apply them, except when I vesicate the 
space behind the ear by a very narrow strip of the plaster, or a 
little blistering-collodium put on with a small brush. Indeed, I 
should not feel inclined to apply even the sinapisms, except w^hen 
the frequently recurring paroxysms should have left their injurious 
traces in the pulmonary circulation or in the mucous membranes 
of the lungs. 

The disease proves fatal by leading on certain disorders of the 
lungs, or by extending its pernicious influences to the hemispheres 
or the cerebellum ; or else it instantly destroys life by cutting short 
the power of the medulla oblongata. The progress of the malady 
towards these several terminations, except the one last named, leads 
it through different phases of those complications from bad to worse. 
All that can be done here is to discriminate carefully the steps 
by which organs are successively invaded, and then trodden 
down and destroyed. If these processes are supposed to be 
congestive, or inflammatory, let them be opposed by the ap- 
propriate means, and that without too much regard to the prime 
disease, which, as I have supposed, is some derangement or 
dyscrasy of the nervous mass itself, a derangement and dyscrasy 
that increases, pari passu, with the successive failure of the organs 
under the dominion of that nervous mass. When the paroxysm 
is coming on, it should be treated by measures calculated to make 
it abort. Throwing cold water in the face is highly recommended ; 
and since the sympathy between the diaphragm and the nerves 
of expression is well known, it is a most reasonable and useful 



190 LARYNGISMUS. 

method. But I have witnessed attempts to re-establish the 
respiratory acts by dashing water in the face that utterly failed 
of any effect — so much so that the paroxysm has proceeded to 
the point of developing the general convulsion — a most untoward 
accident. I may with boldness aver my belief that the diaphragm 
will instantly act if a lump of ice wrapped in a napkin or hand- 
kerchief be applied to the epigastrium and moved over the arch 
of the hypochondria. There is scarcely to be met with a case 
of spasm of any muscle that will not relax upon such an appli- 
cation ; and I am very confident in the correctness of the opinion 
I have already expressed, that our case is essentially one of 
phrenismus and not one of laryngismus. I ought to say that I 
here express only my own opinion, and that I do so with perfect 
respect for the opinions of others who differ from me in sentiment. 
Such an opinion, if founded in truth, cannot but be useful ; if 
unfounded in truth, it can do no evil. Observations of diseases, 
and inferences deduced from such observations, are often erro- 
neous — perhaps more often erroneous than correct and true ; but 
how shall a man contribute his mite of truth or of suggestion 
towards the discovery of any truth, unless he speaks of what he 
seems to see, and of what he believes to be. 

I have given in the treatment of laryngismus immense doses 
of laudanum — indeed, I have pushed the administration of opium 
so far as to feel doubts of the propriety of my action. But I have 
never seen the smallest advantage derived from the medication. 

When the attack has gone on to the stage of convulsion, the 
warm-bath, as is usual, has been resorted to — but I cannot con- 
fidently say with very striking advantage. The convulsion, it is 
true, has come to its close while the patient was in the bath — yet 
it is to be supposed it would have done so without such recourse. 
Custom and probability of benefit will call for it, in all the cases-; 
and I shall in all cases recommend it, as at least a harmless 
method. In fine, I believe our duty in the case consists, first, in 
making a correct diagnosis ; 2d, in presenting proper explana- 
tions to the friends as to the prognosis, which is often unfavor- 
able; 3d, in obviating the provoking causes, as swollen and dis- 
tended gums, which are to be relieved by cutting them ; 4th, in 
a heedful regard to the state of the bowels, whose faulty action 
needs correction ; 5th, in directions as to diet, dress, exposure, 
and all that concerns the hygiene of the case ; 6th, in the use of 



SCARLATINA. 191 

counter-irritants and antispasmodics ; in the exhibition of tonics, 
and in attempts to defeat the demonstration of attack by great 
quietude, and by applying cold to the region of the diaphragm ; 
and, lastly, in conducting the paroxysm, when formed, to the 
earliest and least mischievous possible conclusion, by the warm 
bath and other prompt measures. 

I have not, in any case, made use of venesection. My recol- 
lection of certain cases causes me to lament that I have not done 
so ; and I shall, in any future occurrence of the kind, let blood 
from the arm should the patients exhibit such evidences of 
strength as some that I have attended. This nervous disorder is, 
in one sense, eclampsic ; in a case of puerperal eclampsia I should 
never fail to bleed at the arm. In a strong and well-grown child 
of eight or twelve months, the same principle that should induce 
me to employ phlebotomy in an adult in convulsions might well 
and safely guide me as to the young child. The disease is one 
of the nervous mass, w^hose crasis depends upon the circulation, 
while the circulation equally depends upon that crasis. In such 
violent derangements of the forces of the nervous mass, perhaps 
the most effectual means of control are to be sought in venesection. 



CHAPTER XII 

SCARLATINA. 



Tfiere are three kinds, or rather three degrees of scarlet fever, 
which are severally known as scarlatina simplex, scarlatina angi- 
nosa, and scarlatina maligna. 

Among the diseases of children there is, perhaps, not one that 
is mere dreaded by parents and nurses than this most unmanage- 
able affection ; and I might, perhaps, with propriety add, not one 
concerning whose nature or treatment there exists greater uncer- 
tainty, doubt, and error. 

It is very generally allowed by physicians and by the public 
that scarlet fever is a contagious disorder ; and I presume that 



192 SCARLATINA. 

those writers who take this view of it mean to be understood that 
the cause which produces it is a material generated within the 
body of a patient suffering from it, and from no other source. 

No one has hitherto pretended, however, to know what the 
material cause of scarlatina is ; though we have vague accounts 
of inoculations with it, that have proved successful in propagating 
the malady ; but these accounts require confirmation. 

The notion of the contagiousness of scarlatina, then, is one 
that depends upon faith or argumentation rather than upon evi- 
dence or proof. I do not conceive that w'e are bound to believe, 
because two or more persons in one company or household are 
seized with scarlatina within a certain time after communication 
held with a patient laboring under it, they acquired it from the 
said person — not even if the same sort of circumstance should be 
observed a thousand consecutive times. 

Although it may be true that the cause of scarlet fever is a 
miasm, exhalation, gas, or substance, which is extricated from 
the bodies of the sick — yet if it is true, no one has hitherto proved 
it to be so. The most that can be said of it, therefore, is that it 
is in general supposed to be contagious. 

It seems to me not reasonable to suppose that the sources of 
the poison (if it be a poison) of scarlatina are multifarious. For 
example, I cannot believe it is generated in the bodies of our 
domestic animals. If it is really a contagious thing, and pro- 
duced, not in the domestic animals, but in man — then it is, in all 
probability, produced in man alone, and not in any other living 
thing or source whatever. That is to say, it is not dependent 
upon any vegetable or mineral substance, nor upon a hygrometric, 
electric, or thermometrical condition; nor upon any telluric influ- 
ence, but is developed solely in the human economy, just as the 
human bile, human saliva, or the matter of human perspiration, 
are generated in man alone, and not in other creatures northings. 

Under this statement, it seems to me that many of us might 
well think we have right to doubt as to the contagion of scarlet 
fever, and not only conclude with the late Prof. Dewees, that the 
evidence of its contagion is imperfect, but w^holly deny that it is so. 

And one might well venture to resist the general assertion of 
its contagion, seeing that it so very often breaks forth fearfully in 
places where no suspicion of human intervention can be indulged, 
and that it often enters populous households, affecting only one or 



SCARLATINA. 193 

two, and sparing three or six or eight other members of the family, 
even where not the slightest precaution against its propagation is 
taken by way of quarantine, disinfectants, or other means. 

I have long been fully convinced that scarlatina is a non-con- 
tagious malady, whose cause is to be sought for in some intem- 
perics of the air, or epidemic principle, of whose intimate nature 
I am, however, wholly ignorant. My own mind has for many 
years past been so fully made up on this subject, that I do not 
suppose I shall ever change it so as to believe that scarlatina is 
propagated by contagion. I think that I have come to this con- 
clusion after very careful consideration of the subject, with which 
a medical life so long and active as mine has been, could not but 
have familiarized me. 

While I thus express my own convictions upon this point, I 
hope I shall not be charged with any arrogance or any want of 
due respect for other writers, who, like myself, have merely stated 
their own impressions of the truth, but without enforcing their 
statements by any facts different from those of which I am cog- 
nizant. If any of those writers could have set forth such proofs 
of the contagion of scarlet fever as those which, in regard to variola, 
clearly prove its communicability from person to person, I should 
feel obliged to admit the facts — indeed I should not be able to 
resist the conviction of their force and truth. 

In the case of scarlet fever, however, the facts are so discordant 
that every person is to be left free to form his opinions unbiased 
by the dogmatism either of the public or of medical writers and 
practitioners. It is certainly a very interesting question in prac- 
tice as to whether scarlet fever be contagious or no. Those who 
insist on its contagiousness ought, in all possible cases, to sepa- 
rate the well from the sick, lest the dangerous contagion should, 
through their oversight, spread destructively among their charge ; 
but, I conceive there is a far more interesting question to be set- 
tled relative to its nature — for upon our views of its nature must 
rest our methods of treatment. No empiricism can be safe in a 
case like this ; a case, in which the life or the death of the patient 
must turn, not on a practice based upon a bare summing up 
of statistical returns, but upon a clear and philosophical view of 
the real nature of those deviations of function, and lesions of 
organs that give rise to the phenomena of the malady. 

I wish to inquire, therefore, into the nature of scarlet fever to 
13 



194 SCARLATINA. 

learn what it is ; in what part of the body it is seated ; into the 
sources of the great danger that accompanies the onset of it, and 
the principles that ought to guide us in the treatment of it, as 
well as the method of fulfilling the indications of cure. 

In order to do this, it will not suffice to say, as is so often said, 
that scarlatina is a case of poison in the blood — an expression 
which explains nothing, as, in fact, it means nothing. There is 
a deeper laid principle than this, which w^e ought to discover, and 
must know before w^e shall come to a correct analysis of our own 
thoughts as to the real nature of the disease. 

Those of my brethren who have done me the honor to peruse 
certain of my medical writings, and a greater number of medical 
gentlemen whom I have had the privilege to address in my public 
lectures in the College, are already well acquainted with my views 
as to the generation and maintenance of the blood. As there may 
be some to peruse these Tracts, however, who have not read my 
Letters to the Class, nor my work on Obstetrics, I shall here set 
forth my views upon the subject at large. This I feel obliged to 
do, because 1 can by no other means claim to make myself un- 
derstood, as to my views of the nature of scarlet fever. 

The blood, which amounts in the adult to between five and six 
hundred ounces, is a fluid composed of water, albumen, fibrin, 
and disks, in the proportion of .790, .80, 127, and .3 — taken in 
the order above mentioned. 

The blood is wholly contained within the blood-vessels, which 
are arteries, capillaries, veins, and the heart. It is separated 
from the rest of the body by these vessels, and it maintains its 
nature as blood, only while it is restrained within their bounds. 
It is fair to say, then, that the whole of the blood is contained in 
a sac or cyst, which is multilocular — each tube or vessel consti- 
tuting one cell of that multilocular sac or bag. It is proper to 
state that the blood becomes changed whenever and as soon as it 
quits the cavity of its vessels. When drawn into a cup, it 
coagulates, as it likewise does whenever it happens to be extra- 
vasated within the body ; or, it is changed into the nutrhive ele- 
ment of accretion or growth, whenever it is deposited as supply 
for the detritus of the living active organism. 

This statement is undeniably true ; and if so, the inference is 
good and sound that there exists a direct and vitally important 
relation betwixt the blood and the living vessel, inside of which 



SCARLATINA. 195 

it is blood, but outside of which it cannot exist as blood — but, on 
the contrary, suffers immediate change or metamorphosis. I said 
there is a vital relation betwixt the blood and the vessel in which 
alone it can exist as blood. This is the same as to say that the 
nervous force of the living solid in contact with which the blood 
exists is a necessary condition of such existence. If that nervous 
influence is w^ithdrawn or lessened, the blood coagulates or is 
ready to coagulate. In experiments, the blood is found to coagu- 
late when the nervous force is withdrawn by pithing the spinal 
cord. I think there is no reader of this passage who will not agree 
with me as to the truth of these propositions. But the question 
arises as to what is the blood-vessel ; what is this organ, that 
alone controls the life and all the qualities of the blood, and which 
the blood touches alone, and by which the blood is restrained 
from soaking into, and infiltrating the whole body and converting 
the tissues into what might be called one universal mass of ecchy- 
mosis ? 

It would scarcely be just to say that the blood-vessel is the 
elastic tissue w^hich we find in the arteries, or the muscular, or 
the cellular elements that are found in different parts of the san- 
guiferous apparatus. 

The truth is, that the true blood-vessel is that tissue which the 
blood touches, and that is the one called by the anatomists mem- 
brana vasorum communis, which Mr. Burdach has denominated 
(and I humbly after him) the endangium, or inner lining of the 
vessels. I say that the endangium is the true blood-vessel, since 
it alone penetrates into the interior of the organs, always leaving 
the other coarser coatings on the outside, when it alone goes 
within them to carry the blood for their supply. The endangium 
may justly be denominated the blood-membrane, because it either 
makes the blood by transmitting to its elements the nervous force, 
or because it maintains the blood in a living state by its presence 
and contact. I shall not say that the endangium makes the blood 
by its sole force of innervation, but while I refrain from saying so, 
I beg leave to express my inability to discover any other solid 
besides the endangium, to which I can attribute this power; 
because, if, as is true, the endangium is the only solid that the 
blood touches, it is clear that it is the only solid by or through 
whose agency the force of the nervous mass can be communicated 
to the blood. It is not necessary to raise the question as to whe- 



196 SCARLATINA. 

ther the endangium is in reality organized. It suffices that it is 
the proximate solid as far as the blood is concerned, and that 
the nervous force must be transmitted through it. 

I do not mean to deny the changing and plastic powers of 
cells ; on the contrary, I freely admit that cell-life is an absolute 
force. But it is also true that cell-force cannot be exerted save 
under conditions relative to the cell. 

Even if we suppose that blood-disks are really cells, endowed 
with all the powers of cell-life, it is nevertheless true that the 
necessary conditions of existence of such cells are conditions 
immediately related to the endangium. 

Should this statement be found correct, then it will necessarily 
follow that states of the endangium must influence the blood ; 
that, the endangium being in perfect health and vigor, or the 
reverse, the blood will be healthful, or the reverse. 

The new light shed on the nature of phlebitis, and particularly 
that form of it which is known as crural phlebitis, as well as 
those cases of phlebitis that follow wounds of veins in venesection, 
in amputations, &c. &c., has rendered it clear that the lining 
membrane or endangium may be affected wuth various forms and 
degrees of inflammation, and other pathological conditions. 

In these cases of endangitis we have frequently to observe 
masses of coagulated blood adhering to the walls of the vessels, 
or great deposits of exudation-corpuscles within the membrana 
vasorum commune, vast accumulations of pus within the vascular 
canals, and other results of inflammatory action. 

This being admitted, it appears to me to follow that this en- 
dangium, this blood-membrane is the subject, and indeed the 
frequent seat of pathological modifications that cannot but interest 
the constitution of the blood or its crasis, and so, its conditions 
cannot but exert a great influence upon the health of the indi- 
vidual. 

In chlorosis, or the various forms of the ansemical malady, the 
endangium may be considered as too debilitated to maintain the 
blood in its due crasis, which being lost, the result is the mani- 
festation of signs of the chlorotic malady. 

Another condition of the endangium is concerned, under this 
hypothesis, in the evolution of a great excess of the fibrin of the 
blood, which being in health, as .003, may rise in certain in- 
stances as high as .015. 



SCARLATINA. 197 

In another state of the endangium the disks, which in health 
stand at .127, may rise to .140, or may fall to .030, while the 
water may rise from .790 to .890. 

In certain other conditions, the endangium becomes an organ 
secreting pus, or a pyogenic organ, whose fatal function it is to 
infect the whole mass of the blood with pus-corpuscles. 

If it should be said that all these variations depend on varying 
conditions of the nervous force, I admit that it is so; but, I claim 
that as the endangium is the delimitary membrane of the blood, 
the screen, so to speak, that separates it from the body, and its 
only medium of communication with the body, the nervous force 
is transmitted by it to the blood — it is the organ of that nervous 
force— in the same sense as the retina is the organ or machinery 
of the tubercula quadrigemina or visual brain, or as the organs 
irradiated by the vagus are the organs or machinery of the 
medulla oblongata. 

All organs should be regarded as negative poles of parts 
known or unknown of the nervous mass, whether brain, spinal 
cord, ganglion, or plexus. In this sense, I propose that the en- 
dangium be regarded as the organ of the nervous mass, for the 
transmission or communication of the nervous force to the blood; 
in other words, as the organ that produces the blood. 

Having set forth my views as above, I have now to say that 
scarlatina may be considered as an inflammation of the true 
blood-vessel, or endangium, the inflammation being chiefly ob- 
servable in the capillaries of the skin, of the mouth and throaty 
and of the nostrils. In some of the cases the inflammatory affec- 
tion seizes upon the capillaries of the brain, more rarely, on those 
of the stomach and bowels, &c. 

Seeing that the skin is an organ of vast extent, exceedingly 
vascular, and possessing important relations with the rest of the 
economy, we need feel no surprise to observe the constitutional 
disorder produced by so extensive an inflammation as that of the 
whole derm. As the crasis of the blood depends upon the health- 
ful force of the endangium, it is to be expected that violent and 
extensive disorders of the endangium shall produce great changes 
in the crasis of the blood, and that those changes will exercise a 
pernicious influence throughout the economy. The nervous force, 
dependent as it is on the power of the blood to be charged with 



198 SCARLATINA. 

oxygen, fails under such conditions of the vital fluid, and the 
organs and functions, in succession, become overthrown. 

The skin is not only the general envelope of the body, and an 
organ by means of which a great quantity of carbon is eliminated, 
it is also an organ for the secretion of a considerable amount of 
sebaceous matter, and for the discharge by perspiration of a large 
proportion of the watery element of the body, &c. Lastly, it is 
everywhere an organ of sense, since there is no point upon its 
surface that is not endowed with the sense of touch. All these 
circumstances, as well as common observation, show that it is 
liberally supplied with nerves, most abundantly endowed with 
capillaries, and moreover possessed of a remarkable power of 
coacervation, which, whether it be of the nature of muscularity 
or not, is undetermined and unimportant for the nonce. 

I should think that, reflecting upon the anatomical characters 
of the skin, no person, observing the intense color of a disk of 
skin affected with the inflammation of scarlatina, or noticing the 
rapid flushing of the red tint back upon a part from which the 
circulation has been driven by pressure of the finger, could deny 
the existence there of an active inflammation. Yet it is clear 
that this inflammation does not attack the whole cutis, but only 
its outer or papillary layer. 

If such a great inflammation should attack both the papillary 
and the cellular aspects of the cutis, we should have the proofs 
of it not only in severer pain, but in positive thickening of the 
whole derm. 

In scarlatina, however, the skin retains its ductility, its soft- 
ness, and its natural thickness, from whence the inference is 
good that the inflammation is limited to the outer aspect, or what 
has been called the corpus mucosum of the organ. It ought to 
be observed that such an inflammation greatly modifies the con- 
dition and powers of the sudoriferous and sebaceous glands as 
well as the power of exosmose of the whole exterior layer. 

But if this be a real inflammation, what is it that is inflamed? 
"What is it that gives the scarlet hue ? What is it that causes the 
red color to flush in an instant back again in the capillary tractus 
from whence we may have just forced it out by pressure of the 
fingers ? 

To me it seems that not the papillae only are inflamed, but the 
channels that carry the blood to the whole outer aspect of the 



SCARLATINA. 199 

organs ; and those channels are capillaries whose essential phy- 
sical solid is endangium and naught else. 

There are very few cases of disease that meet the eye of the 
physician, whose sequelae are more characteristic of the ansemical 
malady than scarlatina. 

It is generally followed by remarkable paleness, long debility, 
readily excited palpitation, oedema, endo-cardial symptoms, ana- 
sarca, dropsy of the chest or belly, and other derangements, that 
cannot with reasonableness be assigned to any other causes than 
a vitiated condition of the blood-making faculty ; and, in fact, it 
generally happens that, after the close of violent assaults of scar- 
latina, our attention is called rather to the condition of the haema- 
tosis than to any other pathological problem. 

Many individuals, be it remarked, assailed with scarlatina, in 
the form called malignant, can never succeed in getting the skin 
inflamed ; on the contrary, it is rather dead than inflamed — it is 
engorged and overwhelmed with torrents of blood that it cannot 
transmit — so that, when a finger is pressed upon it in a manner 
to cause a white mark to remain, many seconds elapse before the 
dark carbonated and half grumous blood in its capillaries is seen 
slowly to creep or rather soak back again in the capillary tractus 
from which the pressure had chased it out. 

In some of the cases, the skin acquires from the first a deadly 
paleness, the extremities being cool or cold, while the pulse can- 
not be counted for its frequency, and is a mere thread at the 
wrists. But, the child meanwhile is perishing from the frightful 
inflammation of the fauces, the pharynx, and the larynx. In this 
state the brain seems, in some instances, intact, since the intel- 
ligence is wholly unperverted. 

I presume that here the endangium of the heart, the endocar- 
dium, and that of the aorta and the superior or inferior cava, is 
the seat of the endangitis, and not the endangium of the cutane- 
ous vessels. This is what the vulgar call a case of scarlet fever 
struck in^ — a recession of the malady from the surface to the 
interior of the body. But what is the meaning of struck in ? 
Does any one suppose that scarlatina, like gout, is metastatic ? 
It is not a case of eruption struck in ; but of an original attack 
of inflammation of the great central vessels, under which the 
central organs become incompetent to their office or function. 



200 SCARLATINA. 

Is scarlatina a case of poisoned blood ? I cannot comprehend 
how the cause of scarlatina should poison the blood. 

Many of my friends have said, while we have together attended 
upon cases, " the blood is poisoned ;" " the poison is in the blood ;" 
"the disease is a disease of the blood, which has received its fatal 
dose of the poison." For my own part, I do not admit that there 
is any poison in the case ; ' for I deny the contagiousness, and 
believe in an atmospheric intemperies as causative of the malady. 

If we should say, and truly, the blood is poisoned, I see not 
how scarlet fever should result from it. A narcotic may poison 
us, bat it does so by poisoning our nervous mass, which is our 
only sensible mass. Thus, over-doses of belladonna, by their 
influence on the nervous mass, may give rise to symptoms so 
like those of scarlatina, as to be likely to puzzle the diagnostics 
of the most adept physician who should be called to judge of the 
case from the symptoms only. In a time when scarlatina should 
prevail, he ^vould scarcely avoid attributing to scarlet fever poison 
the red sore throat, and the scarlet rash, the vertigo and heat, and 
the rapid pulse that might come from over-doses of belladonna. 

In many instances we find irremediable depravations of the 
blood manifested, not only in the color of the tissues, in the tem- 
perature, or the pulsations, but also in the psychical disorders 
introduced by it. These psychical affections, as I have many 
times noticed them at the bedside, have appeared to me to be 
identical with those I have often had sad occasions to observe in 
the pyogenic fevers of puerperal w^omen, and in purulent infection 
of the blood from phlebitis or endangitis in men, whether arising 
idiopathically, or whether resulting from wounds in veins, or 
phlebitis extending from heterologue disease of the abdominal 
cavity. 

In relation to the morbid changes suffered by the blood, I shall 
here cite a passage from M. Gerber's Gen. Jinat., p. 302, one 
which I quoted on a former occasion in a paper read before the 
Philadelphia College of Physicians, but which confirms so fully 
my own opinions that I may very properly presume to lay it 
before those who may do me the honor to peruse these Tracts : — 

"Various and very dissimilar causes," says M. G., "may 
bring about coagulation of the eoncrescible fluids of the body, 
the chyle, the lymph, the blood, and some of the products of 
glandular secretion. Among the number of these causes, may 



SCARLATINA. 201 

be reckoned : loss of the solvent medium, particularly the water; 
greatly retarded motion or absolute stasis; the admixture of 
chemical reagents absorbed along with the chyle, the lymph, &c., 
such as acids, salts, pus, mucus, ichor, &c., or that penetrate 
from neighboring parts in virtue of the law of endosmose. To 
these must be added mechanical causes ; injuries of all kinds, 
pressure, bruising, solution of continuity ; and further, the influ- 
ence of unusual temperature — exposure to excessive heat, severe 
cold, &c." 

In taking: the view of scarlet fever that I have now endeavored 
to set forth, I find myself, in practice, freed from the necessity of 
fatiguing my mind in the vain search after a rationale of the 
symptoms, and a discovery of the indications of treatment. 

I have no poison in the blood to eliminate — I do not perceive a 
state of the liver that requires calomel as an alterative. It is not 
a pneumonia nor a gastritis, or duodenitis, or dysentery, or ne- 
phritis that I contend against — but I find in my scarlet fever cases 
a vascular disease, an inflammation of the endangium. If it be 
the capillaries of the skin that are solely affected, I have to treat 
a mere case of scarlatina simplex. If those of the skin, and those 
of the mucous membrane of the fauces only are attacked, then I 
have a scarlatina anginosa. If the skin, the fauces, the Schnei- 
derian membrane, the larynx ; and, a fortiori, the parotids, the 
heart, the lungs, the stomach, or the encephalon are all together 
involved by the inflammation of their capillary endangium, then 
I have a case of malignant scarlatina, and I know that the major 
part of such cases are mortal ones. 

Now, in these three different forms or grades, I see only the 
same disorder ; but I see it rising in importance from the slightest 
attack of simple scarlet fever up to the terrible intensity of the 
most malignant form, merely by the extension of the inflammation 
to the endangium of deep-seated and vital organs whose play is 
necessary to life, which cannot be rescued when, as in too many 
instances, the violence and extent of the disorder transcend, ab 
initio, the powers of recovery. 

But even in some of the cases of scarlatina simplex, the blood 
capillaries of the derm are so severely inflamed as to give rise to 
the most intense constitutional irritation. It may well be supposed 
that some of the samples of scarlatina anginosa will, a fortiori, be 
found dangerously violent. 



202 SCARLATINA. 

This state of the membrana vasorum, by its influence upon the 
health of the blood, exposes the patient to many of the dangers 
referred to in my extract from M. Gerber's General Anatomy. 
In the instances where the pulse can scarcely be felt or counted, 
when the heat of the trunk is not great, and that of the extremi- 
ties below par, the surface livid, the respiration rapid and violent, 
and the breath cool, I believe the nervous power, whose trans- 
mission to the blood through the endangium is indispensable to 
its existence as such, being greatly impeded, the blood tends to 
coagulate, and that the conditions just now referred to do often 
depend on the formation of a coagulum in the heart. There is, 
indeed, good reason to suppose that the heart-clot is one of the chief 
direct causes of the loss of life in scarlatina. In many other kinds 
of sickness, such as phthisis pulmonalis, cancer of the stomach, or 
liver, vast tumors of the ovaria or womb, small-pox, &c. &c., the 
flying pulse that we meet with in the last days of the patient's 
life is due to the presence of a clot formed in the pulmonic heart 
and pulmonary artery. The presence of such a clot is not diffi- 
cult of diagnosis, as will be witnessed by many students of the 
Pennsylvania Hospital, who have verified that diagnosis as made 
by my esteemed colleague and friend, Dr. William Pepper, during 
his clinical lectures at that hospital. 

All the conclusions of medicine, being designed at last to turn 
to the account of the safety or advantage of society, the present 
Tract ought in like manner to include some directions or infer- 
ence of a clinical kind. And here I am free to confess that the 
views I entertain on the subject of our disorder, do not liberate 
me from a sense of doubt and even of incompetency when I come 
to assume the conduct of a case of scarlet fever. 

It is far easier to know diseases than to know how successfully 
to cure them ; because, it has not pleased the Author of nature 
to supply us with therapeutical agents capable of effecting those 
changes in the action of the organs that we should most thank- 
fully possess if He had designed or given them to us. Neverthe- 
less, to cure does not really mean to restore, but rather curare, to 
care for, to take care of, to counsel and to execute as far as in 
us lies, those things that may tend to the recovery. These at- 
tempts are, alas ! often vain attempts, though in the majority of 
them we reasonably expect to see the good fruit of our labors in 
behalf of suffering humanity. 



SCARLATINA. 203 

The cure of the milder forms of scarlatina is very simple. 
There are many such instances in which the patient is ill only 
as far as the dermal covering is concerned ; and when the in- 
flammation of the papillary aspect of *the skin is not violent, it 
often suffices to make use of mere hygienic measures. 

If the pulse is not very frequent, or full — if the head is clear, 
the respiration moderate, the temperature not greatly augmented, 
the intestines not overloaded, there is no clear indication for the 
prescription of any drugs. 

In treating the sick, we ought always conscientiously to avoid 
the administration of drugs and medicines in the cases wherein 
we have not a clear call for them. Indeed, it seems to me some- 
thing criminal to give physic to a patient without a clear and 
express understanding of the motive for exhibiting it. Hence, 
though the patient may be affected with scarlatina, it does not 
behoove us to drug him merely because he is already sick. We 
ought to wait, and watch, in order haply to learn whether the 
disease is about to seek its own fortunate term without our aid. 
If, in a case that tends to a spontaneous cure, we interfere with 
the salutary march of nature, we shall prove to be rather dis- 
turbers than pacificators of the rebellion of the organs, and shall 
be more likely to give an unfavorable turn to the case than to 
lead it to an earlier, an easier, and safer conclusion. 

Let the young reader take notice of a fact that is worthy of his 
careful attention ; it is this, that men of experience, and long and 
deeply versed in the treatment of diseases, give less and fewer 
medicines than the young and new-fledged practitioner. 

It is quite a mistake, and a very common one, both in the young 
profession and in the public, to say that when a man has come to 
a mature age in his career of practice, he has lost his energy, 
because he confides less in the power of drugs than at the com- 
mencement of his medical life. The fact is almost universal that 
experienced physicians give less physic than the young and 
ardent practitioner just out of the schools; and this fact, I repeat, 
is worthy of note, and should be used as a beacon and guide for 
the new beginner. The diminished use of drugs does not arise 
from any mistrust of their real beneficent powers, but from a truer 
and more perfect knowledge of the indications. Let him not 
join the hue and cry of "Go up, thou bald head! — go up, thou 
bald head!" and let them remember the she bears that "tare 



204 SCARLATINA. 

forty- and-two of those children" that derided the gray-haired 
prophets of God. 

To establish by vaccination an inflammation extending from 
the elbow to the shoulder, and involving half the circumference 
of the arm of a child, does not awaken the immediate desire to 
cure it by drugs. On the contrary, everybody is content to wait 
in order to see its spontaneous decline on the tenth and its com- 
plete cure on the eighteenth day : so, in many cases of fever, 
scarlatina, measles, &c. &c., it is our sufficient and whole duty 
merely to watch over and observe the progress of affairs, taking 
care like the consul ne quis capiat detrimenti reipublicce. Hence, 
I urgently advise the young practitioner to take courage to resist 
his impetuous temptation to prescribe medicines, merely because 
the child is sick. In the meantime, let the temperature of the 
apartment and the body be regulated — let the diet and drinks be 
wisely ordained, and we shall often find that, if we decide to 
avoid the use of doses for only four hours, or eight hours, the fever 
will in that space of time have considerably decreased, while the 
various organs of life have in the meantime taken no detriment. 
In eight other hours, we may discover a great diminution of the 
signs of disease, leading us to expect the total disappearance of 
the malady in due, and that no very long time. 

Nothing can prove more gratifying to a medical man than the 
results obtained in this manner. The success commends the 
method to the friends of the patient, who with a little instruction 
from the medical adviser, may be readily led to understand the 
reasonableness and the wisdom of such a method. A physician 
who dares to make such a prognosis and recommend such a 
course of action, obtains the entire confidence of those with whom 
he has these professional relations, and they truly learn to confide 
not only in him but in the medical art. 

It is not, however, in every case that we can feel ourselves 
safe in confiding to nature alone the restoration of the patient. 

If the pulse has risen in frequency, volume, and force, to such 
a degree as to extricate an excessive temperature ; to render the 
patient restless ; to give him general pain, affecting the head, the 
trunk or the limbs ; to accelerate the respiration in an inordinate 
manner — if the stomach has become disordered, with nausea, or 
vomiting, or if the alimentary passages are loaded with the residue 



SCARLATINA. 205 

of digestions retained too long, we shall not feel at liberty to wait 
upon the movements of nature. 

In every instance we ought to inform ourselves whether the 
increased general momentum, or any morbid determination of the 
circulation, menaces the life of the patient; and if we arrive at 
the conclusion that such a state of the circulation is dangerous, 
measures ought to be taken with a view to moderate the impetu- 
osity of the motion. 

In some instances, the operation of an aperient enema may be 
relied upon as sufficient to diminish in a decided manner the 
violence of the circulation, the excess of the respiration, and 
temperature. 

In other examples, the more considerable influence of an 
aperient or purgative medicine is required, for the purpose of 
producing not only a direct sedative result from the increased 
secretions into the cavity of the bowels, but also for the indirect 
advantage derived from the removal of saburra, the presence of 
which provokes even a higher degree of irritation. Even where 
we have no reason to suppose the presence of saburra, we ought, 
if the fever is great, to remove the ordinary contents of the bowels, 
because it is true that those ordinary contents, which in an ordi- 
nary state of the health are not morbidly irritating to the intestine, 
become highly so, in fever, under which the sensibility of the 
alimentary tube is greatly exaggerated. 

In addition to the sedation derivable from the operation of an 
aperient or mild cathartic medicine, a most useful end, of the 
same sort, is obtainable by means of the affusion-bath. 

I have the greatest reason, I think, to recommend the use of 
the affusion, and am indeed so much convinced that it is one of 
our best remedies, that I have rarely failed to prescribe it for my 
scarlatina cases during the last twenty years. 

A large wash-tub should be brought into the chamber, and the 
floor of the tub should be covered with a folded napkin, in order 
that the child's feet may not rest upon the cold wood. 

The child should be placed on his feet in the tub, and sup- 
ported in a stooping posture — when three or four gallons of water, 
containing a portion of vinegar and of the temperature of 92° or 
94°, should be poured upon the nucha and shoulders so as to run 
off at the feet. 

As soon as the affusion is completed, the child should be 



206 SCARLATINA. 

wrapped in a flannel dressing-gown, without wiping the body. 
It is then laid upon the bed, and after twenty or thirty minutes is 
dressed again in its night-clothes. 

It appears to me that this method of using the bath is far pre- 
ferable to the ordinary plunge-bath, which is likely to irritate and 
fatigue the little patient ; whereas, the affusion at 92° while the 
body is at 98° or 100°, produces a delightful refreshment and 
coolness to the heated surface. Certainly, it often happens that, 
children heated, distressed and agitated with fever, become at 
once tranquilized by this process, and soon enjoy a refreshing 
sleep after being laid upon the bed. 

Many years ago, I saw a child seven or eight years of age, 
lying, as I thought, dangerously ill with scarlatina, in Race street 
near Ninth. Its skin was red as a lobster, and it was restless 
and unhappy. I directed the affusion as above. The child re- 
ceived the bath with the greatest satisfaction, was laid upon its 
bed — fell at once into a copious perspiration, which in less than 
six hours removed every vestige of the fever, and even of the 
scarlatina. The case was cut short by a single affusion-bath. I 
have not since that time met with another example of so prompt 
a cure by similar means — but I certainly have met with numerous 
examples of striking benefit procured by this method in cases of 
scarlatina of the several grades. 

I have on many occasions commenced the treatment of scarlet 
fever cases by the exhibition of an emetic of ipecacuanha. It 
seems probable that such a process would prove very salutary 
where a saburral condition of the primae viae is clearly ascertained 
to exist ; and particularly in those instances in which a consider- 
able accumulation of faucial mucus gives an unfavorable pros- 
pect as to the state of the throat in the case. I have not, how- 
ever, of late years been so much in the habit of exhibiting emetics 
in this malady ; still, I believe the plan is a commendable one, 
which ought not to be overlooked or neglected so much as I sup- 
pose it to be by the brethren generally. Little violence is done, 
and little exhaustion produced by the emetic dose of ipecacuanha, 
or powder of alum. 

In general, the inflammation of the papillary body of the skin 
involves the secretory organs of the derm, so that both the unc- 
tuous and perspirable matters fail to be discharged. In conse- 
quence of this dryness of the surface, it is usual to prescribe 



SCARLATINA. 207 

saline draughts and other medicines designed to increase the 
perspiration. These saline mixtures, in general, serve more to 
disorder the stomach than to promote diaphoresis, even in some 
of the ordinary bilious fevers; but in such diseases as scarlatina 
they are really pernicious, since it cannot be reasonably expected 
that they should produce their diaphoretic effect on account of the 
inflamed state of the organs of the perspiration. Certainly, those 
persons who take saline mixtures without being cast into a per- 
spiration by them ought not to expect any good effect — but rather, 
an uneasy state of nausea, which results in no good. Such articles 
appear to me to be sedative or calming only in those instances in 
which sweating follows their employment, an event that is at once 
improbable and very uncommon in scarlatina. 

To perspire freely in scarlatina, is almost to insure a happy 
recovery ; because the outflowing of the perspiration tends directly 
and powerfully to the diminishing of the dermal inflammation. — 
But while that inflammation is maintained at its high stage by the 
strong reaction of the heart and arteries, there is little hope to 
establish such a critical flowing of humors from the pores. 

A far better medicine than the saline draughts so generally 
used, is to be found in a very dilute solution of emetic tartar, of 
w^hich the one hundredth or one hundred and fiftieth of a grain 
may be given to a child two years old. Half a grain of emetic 
tartar, dissolved in a common tumblerful of water, may be given 
in teaspoonful doses once an hour, which might be assumed to 
be the 130th of a grain for the dose. Such doses are powerfully 
sedative by their influence upon the action of the heart, which 
rarely fails to become less violent and impetuous under the use 
of the drug. To let the action of the heart fall even a little in 
intensity is to allow the re-establishment of the perspiration, espe- 
cially if the therapeutic operation be assisted or promoted by 
means of occasional affusion-baths, or by sponging the whole 
surface with w^ater at 85° or 90°. 

If the heart beats strongly and frequently, the blood is driven 
with force and swiftness into the tissues of the organs, and those 
that happen to be the seats of an inflammation become overcharged 
or engorged — heated, extended, reddened, and more painful. If, 
on the contrary, the heart can be made to beat with less force and 
frequency, then the blood reaches the organs with less impetuous 
force and in smaller quantity in equal times ; in which case the 



208 SCARLATINA. 

parts inflamed become less heated, extended, red, and painful — 
which is, to all intents, a lessened degree of inflammation. 

Now, these propositions are so obviously true that I do not 
understand how they can by anybody be denied or rejected ; and 
yet it is a very common thing at the present day to discommend 
the use of venesection in scarlatina. Scarlatina, as I understand 
it, is inflammation of the blood-vessels of the derm — or, to use 
the expression that I prefer, it is endangitis of the cutaneous 
vessels. Nobody denies the usefulness of the lancet in inflam- 
mation of the pleura or meninges of the head, yet it is quite a 
general thing to make an outcry about bleeding in scarlatina. 

If a venesection may at once lessen an inflammation of the 
pleura or peritoneum, it seems to me that a similar method might 
be expected to have a similar effect in an inflammation of the 
skin. 

It is undeniable, that in the great cases of phlebitis (even in 
metro-phlebitis), the use of the lancet has not gained much favor 
in modern practice ; a circumstance that depends rather upon the 
too late determination of the diagnosis, than upon any peculiar 
inapplicability of that method to the form of disease. Patients 
affected with phlebitis do not exhibit the symptoms of that malady 
until they have gone very far in the course, and when those symp- 
toms are at length observed, it is often too late to expect a cure 
from the lancet. I speak here of those cases of phlebitis that 
affect the larger vessels, such, for example, as crural phlebitis 
or milk-leg. In such instances, the disease is rarely understood 
until the crural vessel, or the vessels of the saphena-system have 
become enormously swollen by the secretions, or inflammatory 
exudations, not of the endangium only, but of the cellular sheath 
outside of the real vessel ; venesection in such a state of the case 
would not be more reasonable than a bleeding in pleurisy or 
peritonitis after effusion should have taken place. 

A similar objection does not appear to me to exist as to the 
use of venesection in the endangitis of the cutaneous vessels in 
scarlatina — in which it is rare to find effusion or any exudation. 
The control exerted by a proper bleeding over the ictus cordis^ is 
sufficient, as I have already observed, to lessen the force of the 
injection-power of the heart in the most salutary manner. I 
think that I speak from a very ample experience of the fact. 



SCARLATINA. 209 

That experience has, during many years, confirmed me in the 
use of venesection in scarlatina. 

The prostration of the vital powers observable in the more 
malignant forms of scarlatina is so great in some of the instances, 
that it is clear at the first glance that the lancet is not the proper 
remedy; because, as the lancet is designed to control the power 
of the heart, or the injecting-power, we dare not resort to it where 
we find that power already reduced almost to its last remainders. 

I am of opinion, however, that in these dreadful circumstances, 
which forbid a resort to venesection, there remains little hope in 
any other medical recourse ; and my clinical experience leaves 
upon my mind a strong impression, that in a case in which I 
should not dare to let blood, I should not expect to have the hap- 
piness to see the patient recover. These expressions do not imply 
that I should let blood in every case — for there are many of them 
in which I should not think it necessary to bleed, because I should 
foresee the end, in a perfect recovery, under the use of a few affu- 
sion-baths, occasional draughts of cold orangeade or iced-water^ 
and sponging of the surface ; while I might keep the bowels in 
proper condition by means of laxative enemata, or some gentle 
aperient doses. 

I have had many occasions to regret and mourn over my own 
timidity, or that of my medical brethren in consultation, because, 
when I have wished to bleed, but dared not — or have proposed 
to bleed, but could not on account of objections made to it in 
consultation, I have seen patients lost that might probably have 
been saved. But I have rarely seen recoveries to take place 
when I wished to bleed, but dared not, or could not. 

It is a great matter to keep the respiration clear — because 
without oxygen we die. But a child in scarlatina anginosa or 
scarlatina maligna would die outright, from the obstruction of his 
respiration through the vast collection of tough faucial mucus, that 
is ever found filling the fauces and pharynx of the young patient, 
in our disease. 

It is, therefore, a matter of the extremest necessity to clear out 
for the child not the fauces only, but also the nostrils. 

The fauces may pretty readily be kept free by removing with 

a bit of sponge secured on the end of a pencil-stick, all the mucus 

that maybe collected beyond the isthmus faucium, even far down 

in the pharynx. Upon removing a great mass of tenacious phlegm 

14 



210 SCARLATINA. 

in this manner, the restlessness is instantly lessened, because the 
partial suffocation, caused by the churning of the inspired air 
through the mucus, is removed. 

It ought not, however, to be overlooked, that a young person 
retains the instinctive propensity to breathe only through the 
respiratory orifices, the nares ; and there is little advantage in thus 
removing the faucial mucus if we neglect at the same time to 
clear out the nostrils. For this purpose, I have found great con- 
venience in using slender cones or cylinders cut out of a very 
compact sponge. If these cones are made about an inch or inch 
and a half long, one of them may be, readily and without pain, 
spun betwixt the thumb and finger, deep into the nostril, where 
it absorbs and entangles a quantity of obstructing mucus, which 
is then withdrawn. 

It stands to reason to say, that a child, half choked or as- 
phyxiated by obstruction of the nostrils and fauces, shall be 
greatly comforted, and in a measure preserved from danger by 
the above method. I at least, am confident I have rescued pa- 
tients by this means, that I could not without it have saved. 

To touch the diphtheritic surfaces of the fauces in scarlatina, 
with solutions of nitrate of silver, is a very common practice. I 
am impressed with the conviction that it is not useful in these 
instances to make use of strong solutions of the salt. They do 
not answer a good purpose; nor can they cure the malady, which 
is essentially endangitis of the derm and the throat. It is far 
better to use weak solutions, not exceeding three to five grains to 
the ounce. Such doses do not give pain, nor do they excite an- 
other inflammation ; whereas, the concentrated salt produces an 
inflammation of its own, that is immediately again converted into 
the morbid, and thus aggravated inflammation of the scarlatina. 
It is a pure loss therefore to excite it, and the act serves but to 
aggravate and not to cure. 

Perhaps other physicians may think differently on this point. 
Still, I desire here to do my duty in humbly offering them this 
suggestion, and commending it to their careful observation and 
reflection. 

In some very severe attacks of the scarlatina-diphtheritis of the 
throat, I have allowed of no gargle except very cold infusion of 
lint-seed, which is always comforting to the patient. 

Honey of roses, with a little alum, or with borax, is a very 



SCARLATINA. 211 

serviceable gargle ; as is likewise a mixture of sulphate of quinine 
and sulphate of copper, dissolved in water, and applied by means 
of a throat-brush. A scruple of quinia and half a scruple of the 
sulphate of copper, dissolved in an ounce of water, is a conve- 
nient formula. 

The throat should be dressed wifh a poultice of flaxseed and 
hop-petals, wrapped in the finest flannel, and worn as a cravat„ 

A patient in scarlatina ought not to be blistered. The inflam- 
mation excited by a blister is more apt than not to be instantly 
converted into scarlatina-inflammation, so intense as to transcend 
the powder of recovery, nor to terminate in any other way than that 
of gangrene and mortification. I have seen the w^hole corium cover- 
ing the front of a baby's thorax, fall out in one slough, for having 
been rashly covered with a blistering plaster. These blisters are 
most pernicious things in our cases. 

It appears to me that most of the cases of scarlatina that have 
proved fatal under my observation, have destroyed the patient by 
developing pseudo-membranous croup. Those, however, that 
perish w^ithin the first forty-eight hours die apoplectic. 

Parotid tumors, or rather swellings, which are mumps — scar- 
latina-mumps, are of very bad omen. They add frightfully to 
the pain and tension of parts, and are generally complicated with 
similar swellings of the submaxillary and cervical glands. 

I never saw a patient recover in whom the parotid had gone 
into suppuration. I believe that the best thing to be done in such 
circumstances is to adopt the practice of my friend Dr. Corson, 
of Conshohocken, as advised in his letter to Dr. J. F. Meigs„ 
That letter may be consulted in Dr. Meigs' work on the Diseases 
of Children. 



INDEX. 



A 

Acephalia, 35 

Acid stomach, 75, 86 

Aeration checked by coryza, 58 

Affusion-bath in scarlatina, 205 

Alum, emetic, 133 

Analysis of milk, 67 

Anencephalia, 35 

Aphtha, 54 

Apoplexy, 36, 37, 38 

Articulation, cry from pain in the, 20 

Asphyxia at birth, 37 

from coryza, 60 

cyanosis, 110 
Astomatous foetus, 38 
Atelectasis, 33 
Atrophy, 36 

B 

Bath by affusion, in scarlatina, 205 

Bile, green-colored, 75 

Billard on foramen ovale, 33 

Bitch, milk of the, 70 

Black blood in the brain capillaries, 

94, 110, 114, 116, 117, 118, 119 
Blood of the foetus, 25 
Botalli's foramen, closure of, 32 
Bowel complaints, 63 
Breathing by the nares, 58 

normal and abnormal, 124 



Caput succedaneum, 49 
Case of child born of variolous mo- 
ther, 25 
vrith only one ventri- 
cle, 31 
coryza, 59, 60, 61, 183 
croup, by Dr. Pancoast, 114 



Case of cyanosis, 96, 98, 99, 113 

ear-ache, 19 

ectopy of liver, 34 
by Prof. Eve, 98 

Gintrac, 109, 117 

Evory Kennedy, 25 
of laryngismus, 167, 181 

rheumatism, 21 

Geo. Repplier, 140 

salaam-convulsions, 159-180 
by Dr. Schreiner, 99 
Casein in milk, 69 
Cerise, Dr., quoted, 104 
Children in utero, hygiene of, 26 
Chincough, 152 
Circulation of the foetus, 94 
CoUyrium, 53 

Compressed cord, causes death, 31 
Conjunctivitis, 52 
Cord, how dressed, 43 
how cast off, 43 
Coryza, 57 

cases of, 59, 60, 61 

Denman, Home, Hunter, 
Underwood on, 61 

treatment of, 62 
Cow's milk, 69 
Cries of the organs, 22 
Croup, 126 

alum emetic in, 133 
Pancoast's case of, 141 
Cry of the ear-ache, 19 
Cyanosis, 02 
Cystic cry, 20 



D 

Denman on coryza, 61 
Dessaussure's Mont Blanc, 106 
Diagnosis of children's diseases, 18 
ear-ache, 20 



214 



INDEX. 



Diagnosis of rheumatism, 21 
Diarrhoea, 63 

of milk, 74 
Diet of milk, 71 
Digestive organs of child, 63 

arteries, 65 
Diseases of foetus, 23 
Dress of young child, 87 

E 

Ear-ache, 19 

Ectopy, 34 

Endangitis, 197 

Endangium, the, 194 

Ens-vivum in man, 102 

Erysipelas of navel, 46 

Eve, Professor, his case of cyanosis, 

98 
Ewe's milk, analyzed, 70 
Expression of face in disease, 22 
Eyes inflamed, 51 
Eye-water, 51 



Fainting of foetus at birth, 38 
Flannel cap for coryza, 62 
Flourens on nervous mass, 171 
Foetal circulation, 94 

a 

Gallois, Dr. Le, cited, 105 
Gerber quoted, 200 
Gintrac on cyanosis, 109, 117 
Glisson on irritability, 172 
Goat's milk analyzed, 69 
Graetzer on foetus, 24 
ectopy, 34 
Gripings, 75 
Green stools, causes of, 75 



H 



Haller on irritability, 172 
Hasse on atelectasis, 34 
Head-cry, 20 
Heart, foetal, 94 

a hydraulic machine, 108 
Holding the breath, 129 
Hunger at birth, 67 
Hydrocephalic foetus, 35 
Hygiene of foetus, 26 
Hypertrophy, foetal, 26 



Inflamed eyes, 51 

larynx, 135 



Inflamed mouth, 53 
navel, 46 
nostril, 67, 183 
skin in scarlatina, 197 

Intestinal cry, 20 

Irritability of Glisson and Haller, 172 



Jaundice, 79 



K 



Kennedy, Dr., Evory, case by, 26 
Kopp's asthma, 159 



Language of the organs, 22 
Laryngitis pseudo-membranous, 135 
Laryngismus, 164 

case of, 167, 183 
Larynx, spasm of the, 160, 183 
Life of the foetus, 23 
Ligation of the cord, 43 
Liver, circulation of the, 81 

disorder of the, 82 
Le Gallois, quoted, 105 
Letter of Dr. Pancoast, 142 
Lung-cry, 20 
Lypothymia at birth, 38 

M 

Meconium, of the, 47, 72 
Medicine for the neonatus, 72 
Milk, 68 

analysis of, 67 

the, in the woman, 
the cow, ass, goat, 
ewe, and bitch, 69 
diarrhoea, 74 
Monstrosity, 34 
Muguet, 56 

Muscular force of womb fatal to 
child, 36 

N 

Navel, its formation described, 43 
to treat the, 43 
uncured, 45 
Erysipelatous, 46 
Nervous mass, the, 64, 102, 170, 171 
Non-viable child, 30 
Nostrils, the true respiratory orifices, 
57 

obstructed, danger of, 57 

in typhoid fe- 
ver, 183 
Nurse, wet, the, 84 



INDEX. 



215 



Oken, Professor, quotation from, 103, 

170 
Ophthalmia, 51 
Open foramen ovale in cyanosis, 33 



Pancoast, Professor, his operation of 
tracheotomy, 141 

Pelvic presentations, dangerous to 
child,^ 39 ^ 

Pertussis, 152 

Physiognomical expression in dis- 
eases, 22 

Placenta, faulty states of, 30 

Poison of scarlatina, 200 

Portal system, 81 

Pouting navel, how cured, 44 

Pseudo-membranous croup, 135 

Putting: to the breast, 67 



Rectum, stricture of the, 48 

Repplier, his case, 140 

Respiration checked by coryza, 61 
in cyanosis, 110 
disorders of the, 120 
stigmata of the, 57 

Resuscitation of neonatus, 42 



Salaam-convulsion, 159, 180, 181 
Scarlatina, 191 

a disease of endangium, 
197 
Schwann on the bile, 80 
Schreiner, Dr., his case of cyanosis, 
99 



Septum ventriculorum absent, 31 
Simon, Franz, his analysis of milk, 

69 
Sore eyes, 51 

mouth, 53 
Sour stomach, 75, 86 
Spasm of the larynx, case of, 183 
Spasmodic croup, 127 

laryngitis, 127 
Stethoscope in diseases of foetus, 24 
Stomatitis, 53 
Stricture of rectum, 48 
Suckling, when to commence, 67 



Tie the cord, how to, 43 
Throwing up the milk, 73 
Thrush or aphthae, 54 
Tracheotomy, 140 
Typhoid fever, laryngismus in, 183 

U 

Ulcerated navel, 46 
Umbilicus, inflamed, 46 

how formed, 43 
pouting of the, 44 
Umbilical vesicle, the, 35 
Unborn children are sick, the, 24 
Underwood on coryza, 61 
Urine, retention of by foetus, 36 



Vaccination soon after birth, 25 
Viability and non-viability, 20 
Voices of the organs, 20 



W 



Wet-nurses, 84 



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